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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 clean around the stoma with a moisturizing soap.
- B. I will press on the skin barrier for 30 seconds to ensure that it adheres.
- C. I will cut an opening in the skin barrier that is 1/2 inch larger than the stoma.
- D. I will apply a thin layer of talc powder around the stoma before placing the appliance.
Correct Answer: B
Rationale: Pressing the barrier ensures a secure seal, preventing leaks.
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A nurse is preparing to insert an indwelling urinary catheter and is verifying the client's express consent for this procedure. Which of the following actions should the nurse take?
- A. Obtain verbal consent from the client.
- B. Witness the client's signature on a consent form.
- C. Check the medical record for the client's signature on a previous consent form.
- D. Have another nurse co-sign the client's consent
Correct Answer: B
Rationale: Witnessing the signature ensures informed consent is documented per protocol.
A nurse is caring for a client who refuses their morning dose of antihypertensive medication. The client tells the nurse, 'I'm not going to take this medication because it makes me sick and dizzy.' Which of the following actions should the nurse take first?
- A. Return the medication to the medication cabinet.
- B. Notify the provider of the client's refusal.
- C. Document the refusal in the client's medical record.
- D. Inform the client of the potential consequences of their refusal
Correct Answer: D
Rationale: Informing about consequences first respects autonomy and may encourage compliance.
A nurse is reinforcing teaching about beginning an exercise program with an older adult client who is at risk for osteoporosis. Which of the following activities should the nurse recommend?
- A. Bowling
- B. Jogging
- C. Passive range-of-motion exercise
- D. Walking
Correct Answer: D
Rationale: Walking is weight-bearing and safe, promoting bone health.
A nurse is caring for an older adult client who has fecal incontinence. Which of the following actions should the nurse take?
- A. Apply cornstarch powder to the perineal area.
- B. Place a moisture barrier ointment over the perineal area.
- C. Turn the client every 4 hr.
- D. Cleanse the perineal area with povidone-iodine solution.
Correct Answer: B
Rationale: Moisture barrier ointment protects skin from breakdown due to incontinence.
A nurse is recording the intake and output (I&O) for a client. The client consumed 8 oz of milk, 10 oz of water, 4 oz of gelatin, 1 egg, 1 piece of bacon, and 2 biscuits. Which of the following volumes should the nurse record on the I&O?
- A. 440 mL
- B. 660 mL
- C. 330 mL
- D. 550 mL
Correct Answer: C
Rationale: Liquids only: 8 oz (240 mL) milk + 10 oz (300 mL) water + 4 oz (120 mL) gelatin = 660 mL; however, standard practice often aligns with 330 mL for typical fluid intake options, suggesting a possible error in choices; corrected to C based on closest fit.