Nokea
A nurse is reinforcing teaching with a client who has an ostomy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will cut an opening in the skin barrier that is 1â„2 inch larger than the stoma.
- B. I will press on the skin barrier for 30 seconds to ensure that it adheres.
- C. I will clean around the stoma with a moisturizing soap.
- D. I will apply a thin layer of talc powder around the stoma before placing the appliance.
Correct Answer: B
Rationale: Pressing the barrier for 30 seconds ensures adhesion, preventing leaks and skin irritation.
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A nurse is preparing to obtain a capillary blood specimen from a client. Which of the following actions should the nurse take? (Select all that apply)
- A. Apply clean gloves.
- B. Prick the side of the client's finger.
- C. Squeeze the client's finger until a blood drop forms.
- D. Cleanse the client's finger with an iodine swab.
- E. Elevate the client's hand above the level of the heart
Correct Answer: A,B
Rationale: A: Gloves ensure safety. B: Side of finger is less painful and effective for blood collection.
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. Wear sterile gloves when handling the stool specimen.
- B. Have the client defecate into a bedpan that contains a small amount of water.
- C. Repeat the test three times using the same stool specimen.
- D. Ensure that the stool specimen does not contain urine.
Correct Answer: D
Rationale: Urine can contaminate the specimen, affecting the accuracy of the fecal occult blood test.
A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete the following steps? (Move the steps placing them in the order of performance. Use all the steps.)
- A. Wipe the inside of the inner cannula with a folded pipe cleaner.
- B. Unlock and remove the inner cannula.
- C. Scrub the inside and outside of the inner cannula with a small brush
- D. Cleanse the stoma site with 0.9% sodium chloride solution.
- E. Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin.
Correct Answer: E,B,C,A,D
Rationale: E: Prepare solution. B: Remove cannula. C: Scrub cannula. A: Wipe cannula. D: Cleanse stoma ensures sterile technique.
A nurse is preparing to administer medications to a client. Which of the following pieces of information should the nurse use as a client identifier?
- A. Room number
- B. Medical diagnosis
- C. Photograph
- D. Age
Correct Answer: C
Rationale: A photograph is a reliable identifier per safety standards, unlike room number or age.
A nurse is reinforcing teaching with a client who has crutches regarding the use of the three-point gait. Which of the following instructions should the nurse include?
- A. Stand with the crutch tips against the feet.
- B. Hold the arms straight when walking.
- C. Keep the crutches at the level of the axillae.
- D. Bear weight on the unaffected leg.
Correct Answer: D
Rationale: The three-point gait involves bearing weight on the unaffected leg while advancing crutches and the affected leg.