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A nurse is reinforcing teaching with a client about how to collect a stool specimen. Which of the following instructions should the nurse include?
- A. Avoid placing toilet tissue in the bedpan after defecation.
- B. Urinate after the specimen collection.
- C. Place 1.3 cm (0.5 in) of formed stool into a culture tube.
- D. Keep the specimen in a warm area.
Correct Answer: A
Rationale: Avoiding toilet tissue prevents contamination, ensuring specimen integrity.
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A nurse is participating in a group discussion about complicated grief associated with loss. Which of the following should the nurse identify as an example of exaggerated grief?
- A. A client whose grief response is repressed.
- B. A client whose grief response begins following a terminal diagnosis.
- C. A client whose grief response leads to self-destructive behaviors.
- D. A client whose grief response is triggered by a secondary loss.
Correct Answer: C
Rationale: Exaggerated grief involves intense, harmful reactions like self-destructive behaviors, impairing function.
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 nurse is caring for a client who is postoperative following a laminectomy. Which of the following actions should the nurse take when repositioning the client?
- A. Place the client's arms above her head prior to logrolling.
- B. Place the client in semi-Fowler's position prior to logrolling.
- C. Place the bed in the lowest position before logrolling the client.
- D. Place a pillow between the client's legs prior to logrolling.
Correct Answer: D
Rationale: A pillow maintains spinal alignment during logrolling post-laminectomy.
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. Pad bony prominences before applying a restraint.
- B. Tie the ends of the restraint to the client's bed rail.
- C. Use a square knot to secure the client's restraint to the bed.
- D. Observe the client's skin integrity every 2 hr.
- E. Ensure that 2 fingers can be placed between the restraint and the client.
Correct Answer: A,D,E
Rationale: A: Protects skin. D: Monitors for issues. E: Prevents overly tight restraints.
A nurse is reviewing the laboratory reports of four clients. Which of the following clients should the nurse expect to have a positive fecal occult blood test?
- A. A client who has ulcerative colitis.
- B. A client who has cholecystitis.
- C. A client who uses laxatives.
- D. A client who has stomatitis.
Correct Answer: A
Rationale: Ulcerative colitis causes colon bleeding, leading to a positive test.