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A nurse is reinforcing teaching with a client about blood glucose monitoring. The client becomes quiet and appears distracted while the nurse is providing the instructions. Which of the following responses should the nurse make?
- A. Let's talk about what you're thinking.
- B. Is this something you think you can do?
- C. Are you feeling okay?
- D. Do you need more time to absorb this information?
Correct Answer: A
Rationale: Engaging the client about their thoughts addresses distraction and builds rapport.
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A nurse is caring for a client who is receiving detoxification treatment for an opioid use disorder. As the nurse is preparing to administer a methadone IM injection, the client tells the nurse, 'I am afraid of needles.' Which of the following actions should the nurse take?
- A. Remind the client that they must receive the medication as prescribed.
- B. Tell the client not to worry because the pain will be temporary.
- C. Request a change in the medication route to PO.
- D. Ask one of the client's loved ones to encourage them to receive the IM medication.
Correct Answer: C
Rationale: Requesting a PO route addresses the client’s fear while ensuring treatment.
A home health nurse is visiting a client who has advanced Alzheimer's disease. The client's partner states, 'I miss being able to go places with my friends.' Which of the following is an appropriate response by the nurse?
- A. We can discuss this when you're not feeling overwhelmed.
- B. Have you tried taking your partner with you when you go out?
- C. Tell me more about your expectations.
- D. I understand how you feel. I've had a relative go through the same thing.
Correct Answer: C
Rationale: Asking about expectations opens dialogue and shows empathy, supporting the partner's needs.
A nurse is reinforcing teaching with an older adult client who has urinary incontinence. Which of the following instructions should the nurse include?
- A. Drink citrus juice with meals.
- B. Train the bladder by voiding every 5 hours.
- C. Apply adult diapers at bedtime.
- D. Perform pelvic-muscle exercises.
Correct Answer: D
Rationale: Pelvic-muscle exercises strengthen the pelvic floor, improving bladder control.
A nurse is caring for a client who had an indwelling urinary catheter inserted 3 days ago. Which of the following actions should the nurse take?
- A. Use a catheter securing device to hold the catheter in place.
- B. Obtain urine from the drainage bag if a urinary specimen is required.
- C. Change the catheter bag every 3 days and as needed.
- D. Position the drainage bag higher than the client's bladder.
Correct Answer: A
Rationale: Securing the catheter prevents movement and reduces infection risk.
A nurse is preparing to remove an NG tube for a client who is postoperative following colon surgery. In which sequence should the nurse perform the following steps?
- A. Apply clean gloves.
- B. Disconnect the tube from the suction device.
- C. Instill 50 mL of air into the tube.
- D. Ask the client to take a deep breath.
- E. Pinch and withdraw the tube.
Correct Answer: A,B,C,D,E
Rationale: A: Gloves ensure hygiene. B: Disconnect suction. C: Air clears tube. D: Breath aids removal. E: Pinch prevents leakage.