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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. Urinate after the specimen collection.
- B. Keep the specimen in a warm area.
- C. Avoid placing toilet tissue in the bedpan after defecation.
- D. Place 1.3 cm (0.5 in) of formed stool into a culture tube.
Correct Answer: C
Rationale: Avoiding toilet tissue prevents contamination of the stool specimen.
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A nurse at a long-term care facility is caring for an older adult client who has dementia and is at risk for malnutrition. Which of the following actions should the nurse take to promote an increase in food intake?
- A. Provide the client with finger foods for meals.
- B. Restrict visitors during meals.
- C. Limit snacks between meals.
- D. Provide the client with three large meals each day.
Correct Answer: A
Rationale: Finger foods enhance self-feeding and intake in dementia clients.
A nurse is wearing sterile gloves in preparation for assisting with a client's sterile procedure. While waiting for the procedure to begin, how should the nurse position their hands?
- A. Clasp their hands together in a relaxed position behind their body at their waist.
- B. Interlock their fingers and hold their hands away from their body above their waist.
- C. Keep their arms at the sides of their body with their hands in a relaxed position.
- D. Place one hand over the other against the part of the gown covering their upper body.
Correct Answer: B
Rationale: Interlocking fingers above the waist prevents glove contamination.
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. Provide oral care to the client once every 8 hr.
- B. Use a fan to circulate air in the client's room.
- C. Reposition the client once every 4 hr.
- D. Place the head of the client's bed flat.
Correct Answer: B
Rationale: A fan circulates air, relieving dyspnea by enhancing the feeling of airflow.
A nurse is assisting with the care of a client who has cancer that has metastasized. The client has decided to discontinue chemotherapy treatment. Which of the following responses should the nurse make?
- A. Your quality of life will be compromised if you make this decision.
- B. How will you discuss this decision with your loved ones?
- C. Don't worry. Everything will work out for you.
- D. We should talk about your decision later.
Correct Answer: B
Rationale: Encouraging discussion with loved ones shows empathy and supports the client's autonomy.
A nurse in a provider's office is collecting data from an older adult client. The client states that he is having difficulty sleeping. Which of the following strategies should the nurse recommend to promote sleep?
- A. Drink a glass of milk before bedtime.
- B. Watch television in bed.
- C. Take a long walk before bedtime.
- D. Take a 1-hour nap each day.
Correct Answer: A
Rationale: Milk contains tryptophan, which promotes sleepiness.