Nokea
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.
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A nurse is preparing to perform a fecal occult blood test of stool specimens for a client. Which of the following actions should the nurse plan to take?
- A. Ensure that the stool specimen does not contain urine.
- B. Wear sterile gloves when handling the stool specimen.
- C. Repeat the test three times using the same stool specimen.
- D. Have the client defecate into a bedpan that contains a small amount of water.
Correct Answer: A
Rationale: Urine contamination can cause false positives, compromising test accuracy.
A nurse is collecting data from a client who is immobile and has a potential deep-vein thrombosis. Which of the following findings should the nurse report to the provider?
- A. Clammy skin
- B. Tortuous veins
- C. Bradycardia
- D. Calf swelling
Correct Answer: D
Rationale: Calf swelling is a key sign of DVT, indicating possible venous obstruction needing urgent evaluation.
A nurse is caring for a client who has a terminal illness. The client asks what type of care will be provided as death approaches. Which of the following statements should the nurse make first?
- A. Tell me your expectations about activities related to the end-of-life.
- B. We can talk to the provider about incorporating nonpharmacological pain management in your care.
- C. You can allow your family to visit as often as you wish.
- D. You can provide the name of a spiritual support person we can contact for you.
Correct Answer: A
Rationale: Exploring expectations first ensures care aligns with the client’s needs and preferences.
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 inserting an indwelling urinary catheter for a male client. After inserting the catheter 15 cm (6 in), the nurse feels resistance and no urine flows through the catheter. Which of the following actions should the nurse take?
- A. Inflate the catheter's balloon.
- B. Lower the penis to a 45° angle.
- C. Apply lidocaine gel to the urethra.
- D. Twist the catheter gently.
Correct Answer: D
Rationale: Gentle twisting can navigate urethral obstructions safely without causing trauma.