Nokea
A nurse is reinforcing a teaching plan regarding proper lifting with a client. Which of the following strategies should the nurse include to prevent back injury when lifting an object?
- A. Tighten the abdominal muscles.
- B. Bend at the waist.
- C. Keep legs straight.
- D. Hold object away from the body.
Correct Answer: A
Rationale: Tightening abdominal muscles stabilizes the core, reducing back strain.
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A nurse is reinforcing teaching with a client about advance directives. Which of the following client statements indicates an understanding of the teaching?
- A. A family member will need to witness my signature on my living will.
- B. I need to create advance directives so that I can donate my organs.
- C. I can name my sibling as my designee in my durable power of attorney for health care.
- D. My advance directives can be enforced once my attorney approves them.
Correct Answer: C
Rationale: Naming a sibling as a designee in a durable power of attorney reflects understanding of advance directives.
A nurse is collecting data from a client about bowel elimination. Which of the following statements by the client indicates a risk for impaired bowel elimination?
- A. I drink two hot cups of coffee each morning.
- B. I take a prescribed opioid pain medication at bedtime.
- C. I love to eat apples and black-eyed peas.
- D. I drink an average of 2,000 milliliters of water daily.
Correct Answer: B
Rationale: Opioids slow bowel motility, increasing constipation risk.
A nurse is showing a newly licensed nurse how to use a mechanical lift. Which of the following statements by the newly licensed nurse indicates an understanding of this assistive device?
- A. The lower end of the sling goes below the client's calves.
- B. This type of device is useful for a client who cannot assist.
- C. The sides of the sling are for the client to hold on to.
- D. The device requires the client to use upper body strength.
Correct Answer: B
Rationale: Mechanical lifts are designed for clients unable to assist, reducing injury risk.
A nurse is caring for an adult client who has a developmental disability. The client requires an emergency appendectomy, and the staff cannot reach the appointed guardian. Which of the following is an appropriate action for the nurse to take?
- A. Postpone the procedure until the staff contacts the guardian.
- B. Obtain consent from the client.
- C. Request that the provider sign the consent form.
- D. Prepare the client for surgery with implied consent.
Correct Answer: D
Rationale: In emergencies, implied consent allows life-saving procedures when delaying could harm the client.
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 1â„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 skin barrier for 30 seconds ensures adhesion, preventing leakage.