Nokea
A nurse is reinforcing teaching about beginning an exercise program with an older adult client who is at risk for osteoporosis. Which of the following activities should the nurse recommend?
- A. Bowling
- B. Walking
- C. Passive range-of-motion exercise
- D. Jogging
Correct Answer: B
Rationale: Walking, a weight-bearing exercise, strengthens bones, reducing osteoporosis risk safely.
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A nurse is preparing to set up a sterile field to change a sterile dressing on a client's abdominal wound. Identify the sequence of steps the nurse should take.
- A. Prepare a dry work surface above the waist level.
- B. Open the outside cover of the sterile kit and remove the dust cover.
- C. Grasp the outermost flap of the sterile kit while opening away from the body.
- D. Open each side flap of the sterile kit individually while pulling to the side.
- E. Open the innermost lower flap of the sterile kit while standing away from the sterile field.
Correct Answer: A,B,C,D,E
Rationale: This sequence (A,B,C,D,E) maintains sterility by preparing, opening away, and avoiding contamination.
A nurse is reinforcing teaching with a client about the use of a quad cane. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should wear shoes with smooth soles to help slide my weak leg forward.
- B. I will move the cane forward 18 inches.
- C. I will hold the cane on my stronger side.
- D. I should move my stronger leg forward before moving my weaker leg.
Correct Answer: C
Rationale: Holding the cane on the stronger side enhances stability and support for the weaker side.
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.
A nurse is collecting data from a client who has hypomagnesemia. Which of the following findings should the nurse identify as a positive Chvostek's sign?
- A. Image A
- B. Image B
Correct Answer: A
Rationale: Image A shows facial twitching from tapping the facial nerve, indicating Chvostek’s sign.
A nurse is caring for a client who is postoperative.
Medication Administration Record
0830:
Morphine 10 mg subcutaneous every 3 hr PRN pain
What documentation in the client's medical record requires further action by the nurse.
- A. Temperature 37.5° C (99.5° F)
- B. Client is difficult to arouse.
- C. Respiratory rate 10/min
- D. Pulse oximetry 88% on room air
- E. Pupils are 3 mm, equal, and reactive to light. Blood pressure 99/46 mm Hg
- F. Heart rate 61/min
Correct Answer: B,C,D
Rationale: