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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. Hold object away from the body.
- B. Tighten the abdominal muscles.
- C. Bend at the waist.
- D. Keep legs straight.
Correct Answer: B
Rationale: Tightening abdominal muscles stabilizes the spine during lifting.
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A nurse is collecting data from a client who has a stage 4 pressure injury. Which of the following supplies should the nurse obtain?
- A. Cotton-tipped applicator
- B. Tongue depressor
- C. Adhesive tape
- D. Syringe
Correct Answer: D
Rationale: A syringe is used for irrigation to clean a stage 4 pressure injury with deep tissue involvement.
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. Prepare the client for surgery with implied consent.
- D. Request that the provider sign the consent form.
Correct Answer: C
Rationale: In emergencies, implied consent is appropriate when the guardian is unavailable.
A nurse is observing an assistive personnel (AP) apply a belt restraint to a client. Which of the following actions by the AP requires intervention by the nurse?
- A. Placing the restraint across the client's chest
- B. Applying the restraint over the client's gown
- C. Using a quick-release tie to secure the restraint
- D. Tying the restraint to the bed frame
Correct Answer: A
Rationale: Placing the restraint across the chest restricts breathing; it should be at the waist.
A nurse is caring for a client who has insomnia. Which of the following actions should the nurse take?
- A. Administer prescribed diuretics in the evening.
- B. Use overhead lighting when checking equipment.
- C. Keep the door to the client's room closed.
- D. Provide the client with snug-fitting nightwear.
Correct Answer: C
Rationale: A closed door reduces noise, promoting sleep.
A nurse is preparing to obtain a capillary blood specimen from a client. Which of the following actions should the nurse take? (Select all that apply)
- A. Squeeze the client's finger until a blood drop forms
- B. Prick the side of the client's finger.
- C. Elevate the client's hand above the level of the heart
- D. Cleanse the client's finger with an iodine swab
- E. Using clean gloves
Correct Answer: B, E
Rationale: B: Pricking the side avoids painful areas. E: Clean gloves ensure infection control.