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 apply a thin layer of talc powder around the stoma before placing the appliance.
- B. I will cut an opening in the skin barrier that is 1â„2 inch larger than the stoma.
- C. I will press on the skin barrier for 30 seconds to ensure that it adheres.
- D. I will clean around the stoma with a moisturizing soap.
Correct Answer: C
Rationale: Pressing the barrier ensures adhesion, preventing leaks and maintaining skin integrity.
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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.
Day 3:
Bone Mineral Density DEXA scan -3.8 (-1 or above)
A nurse in a provider's clinic is assisting in the care of an older adult female client.
Based on the client's laboratory and diagnostic results, indicate which of the following provider prescriptions the nurse should expect.
- A. Home health evaluation of home safety
- B. Vitamin D supplement 2,500 units daily
- C. Increase caffeine intake
- D. Physical therapy for muscle-strengthening and balance-training
- E. Increase daily sun exposure
Correct Answer: A,B,D,E
Rationale:
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.
A nurse is collecting data from a client who has hypomagnesemia. Which of the following findings should the nurse identify as a positive Chvostek's sign?
- A. Image A
- B. Image B
Correct Answer: A
Rationale: Image A shows facial twitching from tapping the facial nerve, indicating Chvostek’s sign.
A nurse is caring for a client who has insomnia. Which of the following actions should the nurse take?
- A. Use overhead lighting when checking equipment.
- B. Keep the door to the client's room closed.
- C. Provide the client with snug-fitting nightwear.
- D. Administer prescribed diuretics in the evening.
Correct Answer: B
Rationale: Closing the door reduces noise, promoting a sleep-conducive environment.