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A nurse is reinforcing discharge teaching with a client who has a new diagnosis of a latex allergy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will apply an elastic bandage to a cut.
- B. When cleaning, I like to use dishwashing gloves.
- C. On my son's birthday I plan to buy balloons.
- D. I will use ink pens for writing.
Correct Answer: D
Rationale: The correct answer is D: "I will use ink pens for writing." This statement indicates an understanding of the teaching because ink pens do not contain latex, thus reducing the risk of exposure for someone with a latex allergy. Elastic bandages (choice A) typically contain latex, dishwashing gloves (choice B) may contain latex, and balloons (choice C) are commonly made of latex, all of which could trigger an allergic reaction. Therefore, using ink pens for writing is the safest choice to avoid latex exposure.
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A nurse is checking a client's bowel sounds. At which of the following times should the nurse auscultate the client's abdomen?
- A. After palpating the abdomen
- B. Prior to percussing the abdomen
- C. After checking for kidney tenderness
- D. Prior to inspecting the abdomen
Correct Answer: B
Rationale: The correct answer is B: Prior to percussing the abdomen. Auscultation of bowel sounds should be done before percussing as it helps to assess the presence and quality of bowel sounds without causing any interference from other assessment techniques. Palpation (choice A) can stimulate bowel sounds, leading to inaccurate assessment. Checking for kidney tenderness (choice C) and inspecting the abdomen (choice D) are unrelated to auscultating bowel sounds.
A nurse is obtaining a urine specimen for culture and sensitivity via a straight catheterization. Which of the following actions should the nurse take?
- A. Collect urine from the catheter's port.
- B. Use a sterile specimen container.
- C. Use sterile water to inflate the balloon.
- D. Instruct the client to clean from front to back with an antiseptic solution.
Correct Answer: B
Rationale: The correct answer is B: Use a sterile specimen container. This is crucial to prevent contamination of the urine sample, ensuring accurate culture and sensitivity results. Sterile container minimizes the risk of introducing bacteria from the environment. Option A is incorrect because collecting urine from the catheter's port may introduce contaminants. Option C is incorrect as sterile water is not used to inflate the balloon but rather sterile saline. Option D is incorrect because cleaning from front to back is not relevant to obtaining a urine specimen via catheterization.
A nurse is checking the apical pulse of a client who is taking several cardiovascular medications. Which of the following actions should the nurse take?
- A. Count the apical pulsations for a full minute.
- B. Check the apical pulse with a Doppler device.
- C. Use the diaphragm of the stethoscope to listen to the apical pulsations.
- D. Press the stethoscope firmly against the client's skin.
Correct Answer: A
Rationale: The correct answer is A: Count the apical pulsations for a full minute. This is because counting the apical pulse for a full minute provides the most accurate assessment of the client's heart rate. It allows for any irregularities or fluctuations in the pulse to be detected.
Choice B is incorrect as using a Doppler device is not necessary for routine assessment of the apical pulse. Choice C is incorrect as the bell of the stethoscope, not the diaphragm, should be used to listen to the apical pulsations for better sound transmission. Choice D is incorrect as pressing the stethoscope firmly against the client's skin can create artifact noise and interfere with accurate auscultation.
A nurse is collecting data about a client's skin turgor. Which of the following actions should the nurse take?
- A. Lightly palpate the skin using the fingertips.
- B. Press the skin over the client's ankle bone.
- C. Observe for nonblanching, pinpoint-size, red or purple spots on the skin of the abdomen.
- D. Grasp a fold of skin on the client's forearm or near the sternum.
Correct Answer: D
Rationale: Correct Answer: D
Rationale: Grasping a fold of skin on the client's forearm or near the sternum is the appropriate method to assess skin turgor. Skin turgor is the skin's ability to return to normal after being pinched. By grasping the skin and observing how quickly it returns to its original state, the nurse can assess the client's hydration status accurately. This method is commonly used and recommended for assessing skin turgor.
Incorrect Choices:
A: Lightly palpating the skin using the fingertips does not provide an accurate assessment of skin turgor.
B: Pressing the skin over the client's ankle bone is not the standard method for assessing skin turgor.
C: Observing for nonblanching, pinpoint-size, red or purple spots on the skin of the abdomen is unrelated to assessing skin turgor and indicates a different condition.
A nurse is caring for a client who requires contact precautions. Which of the following actions should the nurse take?
- A. Wear a mask when entering the client's room.
- B. Remove potted plants from the room.
- C. Allow the client to leave the room every 2 hr.
- D. Dedicate equipment and supplies for use with the client.
Correct Answer: D
Rationale: The correct answer is D: Dedicate equipment and supplies for use with the client. This is essential for preventing the spread of infection. By dedicating equipment to the client, the nurse reduces the risk of contaminating other clients. Choice A is incorrect because wearing a mask is not necessary for contact precautions unless respiratory droplets are a concern. Choice B is irrelevant to contact precautions. Choice C is incorrect as allowing the client to leave the room frequently can increase the risk of spreading infection.