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A nurse is reinforcing teaching with a client who has diabetes mellitus about using a glucometer to monitor her blood glucose. Which of the following actions should the nurse identify as an indication that the client understands the instructions?
- A. Uses the side of a fingertip as the puncture site
- B. Uses the ball of a finger as the puncture site
- C. Avoids using the thumbs as puncture sites
- D. Avoids using the fingers of her dominant hand as puncture sites
Correct Answer: A
Rationale: Using the side of the fingertip is less painful and provides accurate blood samples.
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A nurse is assisting with teaching a class of newly licensed nurses about the first phase of wound healing. Which of the following processes should the nurse include?
- A. Inflammation
- B. Remodeling phase
- C. Maturation
- D. Proliferation
Correct Answer: A
Rationale: Inflammation is the first phase of wound healing, initiating hemostasis and infection prevention.
A nurse is reinforcing teaching with a family member about how to position a client when administering enteral feedings at home. Which of the following statements from the family member should the nurse identify as an indication that he understands the instructions?
- A. I will turn my mother on her left side during the feeding.
- B. I will position the head of the bed 45 degrees during the feeding.
- C. I will allow the position my mother finds most comfortable during the feeding.
- D. I will elevate the head of the bed 10 degrees during the feeding.
Correct Answer: B
Rationale: Elevating the bed 45 degrees prevents aspiration and aids digestion during feedings.
A nurse is reinforcing teaching about the manifestations of hyperglycemia with a client who has diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?
- A. My breath may have a fruity odor.
- B. I will be more thirsty than usual.
- C. My appetite will be decreased.
- D. I might experience blurry vision at times.
Correct Answer: B
Rationale: Thirst indicates hyperglycemia as the body attempts to excrete excess glucose, causing dehydration.
A nurse is assisting with teaching a client who is on a low potassium diet. Which of the following instructions should the nurse include?
- A. Choose orange juice instead of apple juice.
- B. Replace sugar with molasses when baking.
- C. Eat granola for breakfast.
- D. Avoid using salt substitutes when cooking.
Correct Answer: D
Rationale: Salt substitutes contain potassium chloride, increasing potassium intake, which should be avoided.
A nurse is assisting with the care of a client who arrives at the emergency department after an industrial explosion. The nurse inspects the wound on the client's leg and finds torn skin tissue underneath. The nurse should report this as which of the following types of wounds?
- A. Contusion
- B. Abrasion
- C. Laceration
- D. Puncture
Correct Answer: C
Rationale: Laceration involves torn skin with irregular edges, matching the description of torn tissue from an explosion.