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A nurse is reinforcing discharge teaching about fecal occult blood testing with a client. Which of the following instructions should the nurse include in the teaching?
- A. Discontinue supplements containing vitamin C 24 hr before the test.
- B. Refrain from consuming pork 7 days before the test.
- C. Place a thick layer of stool on the specimen card.
- D. Urinate prior to collecting the stool specimen.
Correct Answer: D
Rationale: Urinating first prevents urine contamination of the stool specimen.
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A nurse is planning to provide postmortem care for a client who requires an autopsy. Which of the following actions should the nurse plan to take?
- A. Place an identification tag on the outside of the client's shroud.
- B. Remove the client's dentures and give them to the client's family.
- C. Wear sterile gloves when cleaning the client's body.
- D. Ask the assistive personnel to document the client's time of death.
Correct Answer: A
Rationale: An ID tag on the shroud ensures proper identification for autopsy purposes.
A charge nurse is observing a newly licensed nurse caring for a client group. Which of the following statements by the newly licensed nurse indicates an understanding of infection control principles?
- A. I will rinse the contaminants from a bedpan with hot water.
- B. I will wear sterile gloves when bathing a client who is incontinent.
- C. I will use disinfectant to clean the blood pressure cuff after use on a client.
- D. I will double-bag a client's linens each day.
Correct Answer: C
Rationale: Disinfecting equipment like a BP cuff prevents cross-contamination between clients.
A nurse is collecting data from a client who reports an inability to cope because of their recent job loss. Which of the following actions should the nurse take?
- A. Tell the client to think about something else.
- B. Ask the client to describe their support system.
- C. Ask the client why they're unable to cope.
- D. Tell the client that everything will be okay.
Correct Answer: B
Rationale: Assessing the support system identifies resources to help the client cope.
A nurse is caring for a young adult client who is postoperative and requires physical therapy, pain management, and dietary advancement. The nurse enters the client's room and finds them dressing and stating that they are going home. Which of the following actions should the nurse take?
- A. Administer a sedative medication to the client.
- B. Have the client sign an against medical advice form.
- C. Tell the client that the surgeon will prescribe restraints if they try to leave.
- D. Explain to the client that they cannot leave until the surgeon discharges them.
Correct Answer: B
Rationale: An AMA form documents the client's informed decision to leave against advice.
A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about the proper use of restraints. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
- A. Observe the client's skin integrity every 2 hr.
- B. Use a square knot to secure the client's restraint to the bed.
- C. Ensure that 2 fingers can be placed between the restraint and the client.
- D. Tie the ends of the restraint to the client's bed rail.
- E. Pad bony prominences before applying a restraint.
Correct Answer: A,C,E
Rationale: A: Frequent skin checks prevent injury. C: Two fingers ensure proper fit. E: Padding protects bony areas.