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A nurse is reinforcing teaching with a client about using guided imagery to manage chronic pain. Which of the following statements by the client indicates an understanding of this technique?
- A. I'll use focused breathing to control my pain.
- B. I'll listen to my favorite music to take my mind off the pain.
- C. I'll learn to notice the sensation of muscle tension.
- D. I'll think about my grandfather's farm to reduce pain.
Correct Answer: D
Rationale: Guided imagery involves visualizing a calming scene (e.g., a farm) to distract from pain.
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A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?
- A. Add 0.5 mL of diluent to the medication.
- B. Use a filter needle to aspirate the medication.
- C. Inject air into the ampule prior to drawing the medication into a syringe.
- D. Cleanse the tip of the ampule with an alcohol swab after opening.
Correct Answer: B
Rationale: A filter needle prevents glass particles from being drawn into the syringe from the ampule.
A nurse is collecting data from a client who is 2 days postoperative following the placement of a colostomy. Which of the following findings should the nurse report to the provider?
- A. The stoma is draining a small amount of liquid stool.
- B. The stoma protrudes slightly from the abdomen.
- C. The stoma bleeds lightly when touched.
- D. The stoma appears dark in color.
Correct Answer: D
Rationale: A dark stoma indicates potential necrosis or ischemia, requiring immediate provider attention.
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 will move the cane forward 18 inches.
- B. I will hold the cane on my stronger side.
- C. I should wear shoes with smooth soles to help slide my weak leg forward.
- D. I should move my stronger leg forward before moving my weaker leg.
Correct Answer: B
Rationale: Holding the cane on the stronger side provides optimal support and balance for the weaker side.
A nurse is reviewing the laboratory results for a client who reports vomiting and diarrhea for 2 days. Which of the following laboratory findings should the nurse expect?
- A. Hypocalcemia
- B. Hypermagnesemia
- C. Hyponatremia
- D. Hyperkalemia
Correct Answer: C
Rationale: Hyponatremia occurs from fluid and sodium loss in vomiting and diarrhea.
A nurse is planning to obtain a client's oxygen saturation. Which of the following might influence the result of this test?
- A. The client has an elevated hemoglobin level.
- B. The client is wearing nail polish.
- C. The client is wearing a ring.
- D. The client has a fever.
Correct Answer: B
Rationale: Nail polish can block the pulse oximeter's light, leading to inaccurate oxygen saturation readings.