Nokea
A nurse is providing end-of-life care to a client who is experiencing dyspnea. Which of the following actions should the nurse take?
- A. Provide oral care to the client once every 8 hr.
- B. Reposition the client once every 4 hr.
- C. Place the head of the client's bed flat.
- D. Use a fan to circulate air in the client's room.
Correct Answer: B
Rationale: Repositioning helps relieve dyspnea by improving lung expansion and comfort.
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A nurse is collecting data from a client who has a BMI of 29. The nurse should document that the client is in which of the following weight categories?
- A. Obese
- B. Overweight
- C. Underweight
- D. Ideal body weight
Correct Answer: B
Rationale: A BMI of 25-29.9 is classified as overweight.
A nurse is reinforcing teaching with a client who has an ostomy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will clean around the stoma with a moisturizing soap.
- B. I will press on the skin barrier for 30 seconds to ensure that it adheres.
- C. I will cut an opening in the skin barrier that is 1/2 inch larger than the stoma.
- D. I will apply a thin layer of talc powder around the stoma before placing the appliance.
Correct Answer: B
Rationale: Pressing the barrier ensures a secure seal, preventing leaks.
A nurse is reinforcing teaching with a client about the use of a quad cane. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should move my stronger leg forward before moving my weaker leg.
- B. I will hold the cane on my stronger side.
- C. I will move the cane forward 18 inches.
- D. I should wear shoes with smooth soles to help slide my weak leg forward.
Correct Answer: B
Rationale: Holding the cane on the stronger side provides optimal support.
A nurse is caring for a client who requires a sterile dressing change. The nurse should recognize that the surgical field has been contaminated if which of the following actions occur?
- A. A pair of sterile forceps is allowed to rest in a container of sterile water on the field.
- B. The sterile solution is poured with the bottle held over the field.
- C. Unnecessary sterile items are placed on the field.
- D. The handle of a pair of sterile scissors is resting 5 cm (2 in) from the field's edge.
Correct Answer: B
Rationale: Pouring over the field risks contamination from the bottle.
A nurse is caring for a client who is postoperative and is preparing to walk for the first time in several days. Which of the following instructions should the nurse give the client to prevent orthostatic hypotension?
- A. Use your incentive spirometer.
- B. Dangle your legs over the side of the bed.
- C. Increase your intake of protein.
- D. Perform regular isometric exercises.
Correct Answer: B
Rationale: Dangling legs helps acclimate the body to positional changes, reducing hypotension risk.