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A nurse is reinforcing discharge teaching with a male client who has an indwelling urinary catheter. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will empty my drainage bag once a day.
- B. I will apply antiseptic ointment to the tip of my penis.
- C. I will keep the drainage bag below the level of my waist.
- D. I will clamp the tube when I go for a walk.
Correct Answer: C
Rationale: Keeping the bag below waist level prevents urine backflow, reducing infection risk.
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A nurse is collecting data about cranial nerve function from an adult client. Which of the following images depicts the method the nurse should use to check the function of the hypoglossal cranial nerve (XII)?
- A. Image A
- B. Image B
- C. Image C
- D. Image D
Correct Answer: A
Rationale: Image A shows tongue deviation testing, specific to hypoglossal nerve (XII) function.
Nurses' Notes Day 1:
Collecting client data on food safety.
Raw meats and raw vegetables are prepared together on one cutting board. Refrigerator is set to 6.7° C (44° F)
Leftovers are discarded after 7 days in refrigerator. Frozen foods are defrosted on the countertop.
Client washes hands for 10 seconds before cooking.
Leftovers are refrigerated after sitting on the countertop for 3 hr.
Reinforced client teaching about food safety. Follow-up visit scheduled in 2 weeks.
Day 14:
At client's home to collect follow-up data on food safety. Uses one cutting board to prepare raw meats and a different cutting board to prepare raw vegetables.
The refrigerator is set to 5.6° C (42° F).
Leftovers are discarded after 2 days in refrigerator. Frozen foods are defrosted in the refrigerator.
Client washes hands for 15 seconds before cooking.
A home health nurse is assisting in the care of a client. Select the 4 findings that indicate an understanding of the reinforced teaching.
- A. Use of cutting board
- B. Amount of time washing hands
- C. Time leftovers sit unrefrigerated on countertop
- D. Refrigerator temperature
- E. Defrosting of frozen foods
- F. Leftover storage time in refrigerator
Correct Answer: A,B,E,F
Rationale:
A nurse is reinforcing teaching with a client about advance directives. Which of the following client statements indicates an understanding of the teaching?
- A. I need to create advance directives so that I can donate my organs.
- B. My advance directives can be enforced once my attorney approves them.
- C. A family member will need to witness my signature on my living will.
- D. I can name my sibling as my designee in my durable power of attorney for health care.
Correct Answer: C
Rationale: A witness, often a family member, validates the living will, reflecting procedural understanding.
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. Reposition the client once every 4 hr.
- B. Use a fan to circulate air in the client's room.
- C. Place the head of the client's bed flat.
- D. Provide oral care to the client once every 8 hr.
Correct Answer: B
Rationale: A fan reduces breathlessness sensation, improving comfort in dyspnea.
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. Apply clean gloves.
- C. Prick the side of the client's finger.
- D. Elevate the client's hand above the level of the heart.
- E. Cleanse the client's finger with an iodine swab.
Correct Answer: B,C,E
Rationale: B: Infection control. C: Proper site. E: Disinfection; A causes hemolysis, D reduces blood flow.