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A nurse is reinforcing teaching with a client who has diabetes mellitus about reducing the risk for a stroke. Which of the following statements by the client indicates an understanding of the teaching?
- A. I can decrease my risk for a stroke by losing excess weight.
- B. My risk for a stroke increases if my HbA1c level is 5 percent or less.
- C. Having a total cholesterol level below 200 mg/dL increases my risk for a stroke.
- D. My provider might prescribe a glucocorticoid regimen to decrease my risk for a stroke.
Correct Answer: A
Rationale: Losing excess weight reduces risk factors such as hypertension and diabetes complications, which are linked to stroke risk, indicating understanding of the teaching.
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A nurse is reinforcing teaching with the family of a client who has methicillin-resistant Staphylococcus aureus (MRSA) of a leg wound and is on contact precautions. Which of the following statements by a family member indicates an understanding of the teaching?
- A. There is no cure for MRSA.
- B. We will need to wear masks when we are in the hospital room.
- C. MRSA only occurs in health care facilities.
- D. We should remove gloves before leaving the hospital room.
Correct Answer: D
Rationale: Removing gloves before leaving prevents the spread of MRSA, consistent with contact precautions.
A nurse is assisting with the care of a client who had a bronchoscopy 12 hr ago. Which of the following findings should the nurse report to the provider?
- A. The client has inspiratory stridor
- B. The client reports a sore throat.
- C. The client's sputum has streaks of blood.
- D. The client's temperature is 38.6°C / 101.4°F
Correct Answer: A
Rationale: Inspiratory stridor indicates possible airway obstruction or swelling post-bronchoscopy, a serious complication requiring immediate reporting.
A nurse is checking the abdominal incision of a client who is 24 hr postoperative. The nurse finds wound evisceration with protruding abdominal contents. The nurse should place the client into which of the following positions?
- A. Trendelenburg with legs extended
- B. Supine with knees flexed
- C. Semi-Fowler's with legs extended
- D. Left-lateral with knees flexed
Correct Answer: B
Rationale: Supine with knees flexed relaxes abdominal muscles, reducing pressure on the eviscerated wound until surgical intervention.
A nurse is reinforcing teaching with a client about breast self-examinations. Which of the following statements by the client indicates an understanding of the teaching?
- A. It is common for the skin on my breasts to dimple.
- B. I will perform breast exams every other month.
- C. It is common for one breast to be larger than the other.
- D. I will perform breast exams the day my period begins.
Correct Answer: C
Rationale: It is normal for one breast to be slightly larger than the other, reflecting an understanding of breast self-examination teaching.
A nurse is assisting with the plan of care for a client who has aspiration pneumonia and hypoxia. Which of the following actions should the nurse plan to take?
- A. Initiate fall precautions.
- B. Apply petroleum jelly to the client's nares.
- C. Implement contact precautions.
- D. Maintain the client in a supine position.
Correct Answer: A
Rationale: Hypoxia increases fall risk due to weakness or confusion, making fall precautions essential in aspiration pneumonia care.