A nurse is preparing to transfer a client from a bed to a chair. The client can bear partial weight and has upper body strength. What device should the nurse use?
- A. Mechanical lift
- B. Gait belt
- C. Slide board
- D. Stand-assist lift
Correct Answer: D
Rationale: A stand-assist lift is the correct choice in this scenario. This device is suitable for clients who can bear partial weight and have upper body strength, as it allows them to actively participate in the transfer process. A mechanical lift is typically used for clients who are non-weight bearing or have limited mobility. A gait belt is used for providing support and stability during walking or transferring short distances. A slide board is used for transferring clients who are unable to bear weight and need assistance moving from one surface to another.
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A nurse is preparing to perform a routine abdominal assessment for a client. Which action should the nurse take?
- A. Palpate the abdomen before auscultation
- B. Inspect the abdomen after palpation
- C. Auscultate before palpation
- D. Start by percussing the abdomen
Correct Answer: C
Rationale: The correct answer is to auscultate before palpation when performing an abdominal assessment. This sequence is crucial to prevent altering bowel sounds. Starting with palpation (Choice A) can lead to false interpretations of bowel sounds due to stimulation of the intestines. Inspecting the abdomen after palpation (Choice B) can also potentially alter the assessment findings. Starting with percussion (Choice D) is not recommended as it should come after auscultation to further assess underlying structures.
A charge nurse discovers that a nurse did not notify the provider that a client's condition had changed. The charge nurse should identify that the nurse is accountable for which of the following torts?
- A. Negligence
- B. Assault
- C. Battery
- D. Defamation
Correct Answer: A
Rationale: The correct answer is A: Negligence. Negligence in nursing occurs when a healthcare provider fails to take appropriate action that a reasonably prudent provider would take in a similar situation, such as not notifying the provider of changes in a client's condition. In this scenario, the nurse's failure to inform the provider of the client's changed condition constitutes negligence. Choices B, C, and D are incorrect. Assault involves the intentional threat of bodily harm to another person, battery is the intentional harmful or offensive touching of another person without their consent, and defamation is the act of making false statements about someone to a third party that harms that person's reputation.
A client has a new prescription for a metered-dose inhaler (MDI). What instruction should the nurse include?
- A. Inhale the medication for 1 second
- B. Shake the inhaler vigorously before use
- C. Hold the inhaler 1-2 inches from the mouth
- D. Exhale immediately after inhalation
Correct Answer: C
Rationale: The correct instruction for a client using a metered-dose inhaler (MDI) is to hold the inhaler 1-2 inches from the mouth. This distance allows for the proper delivery of the medication into the lungs. Choice A is incorrect because the duration of inhalation can vary depending on the medication, and 1 second may not be adequate. Choice B is incorrect as shaking the inhaler vigorously is not necessary for all MDIs and can lead to inaccurate dosing. Choice D is incorrect as the client should hold their breath for about 10 seconds after inhalation to allow the medication to deposit in the lungs.
A client is being taught about measures to promote sleep for insomnia. Which client statement indicates understanding?
- A. I will take naps during the day to help me sleep at night
- B. I should drink caffeine to help me stay awake during the day
- C. I should reduce my fluid intake 2 hours before bedtime
- D. I should exercise right before bed to tire myself out
Correct Answer: C
Rationale: The correct answer is C. By reducing fluid intake 2 hours before bedtime, the client can prevent nighttime awakenings to urinate, which promotes better sleep. Napping during the day (choice A) may interfere with nighttime sleep. Drinking caffeine (choice B) can disrupt sleep patterns. Exercising right before bed (choice D) can actually stimulate the body and make it harder to fall asleep.
A nurse is teaching a client with diabetes mellitus about foot care. What is the most important instruction the nurse should include?
- A. Apply lotion between the toes after bathing
- B. Inspect feet daily for injuries
- C. Wear shoes only indoors
- D. Cut toenails in a rounded shape
Correct Answer: B
Rationale: Inspecting feet daily for injuries is crucial for clients with diabetes to prevent unnoticed wounds from becoming infected. This instruction is the most important as it helps in early detection and management of foot problems. Choice A is incorrect because applying lotion between the toes can lead to excessive moisture, increasing the risk of fungal infections. Choice C is wrong as wearing shoes indoors can also lead to foot issues. Choice D is incorrect because cutting toenails in a rounded shape can result in ingrown toenails, posing a risk for infection.
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