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A nurse is reinforcing teaching with a client who is about to start using a standard walker. Which of the following statements by the client indicates an understanding of the instructions?
- A. I'll keep my elbows slightly bent when I grasp the walker.
- B. I'll slide the walker and move it about a foot in front of me.
- C. I'll move the walker and my stronger leg ahead at the same time.
- D. I'll keep the height of my walker adjusted, so I lean slightly forward.
Correct Answer: A
Rationale: Slightly bent elbows ensure stability and comfort when using a walker.
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A nurse is caring for a young adult client who is postoperative and requires physical therapy, pain management, and dietary advancement. The nurse enters the client's room and finds them dressing and stating that they are going home. Which of the following actions should the nurse take?
- A. Administer a sedative medication to the client.
- B. Explain to the client that they cannot leave until the surgeon discharges them.
- C. Have the client sign an against medical advice form.
- D. Tell the client that the surgeon will prescribe restraints if they try to leave.
Correct Answer: C
Rationale: Signing an AMA form documents the client's informed decision to leave against advice.
A nurse in a long-term care facility is preparing to administer medications to a client who has advanced dementia and does not have an identification band. Which of the following actions should the nurse take to verify the client's identity?
- A. Review the client's photograph in the medical record.
- B. Request an assistive personnel to identify the client.
- C. Ask the client to state their room number.
- D. Have the client state their phone number.
Correct Answer: A
Rationale: A photograph ensures accurate identification, critical for a client with dementia unable to self-identify.
A nurse is collecting data from a client who has diabetes mellitus. The nurse should ask which of the following to determine the client's ability to provide foot self-hygiene?
- A. Do you have any problems taking care of your feet?
- B. Do you go barefoot at home?
- C. Have you noticed any problems with foot swelling?
- D. Have you had a problem with ingrown toenails?
Correct Answer: A
Rationale: This directly assesses ability to perform foot care, critical for diabetes management.
A nurse is caring for a postoperative male client in the surgical unit. Click to highlight the documentation in the client's medical record that requires further action by the nurse. Select all that apply
- A. Respiratory rate 10/min
- B. Pulse oximetry 88% on room air
- C. Blood pressure 99/46 mm Hg
- D. Morphine 10 mg administered subcutaneously
Correct Answer: A,B,D
Rationale: A: Low respiratory rate suggests opioid depression. B: Low SaO2 indicates hypoxemia. D: Morphine dose may need reassessment due to side effects.
A nurse is caring for a client who is postoperative following a laminectomy. Which of the following actions should the nurse take when repositioning the client?
- A. Place the client's arms above her head prior to logrolling.
- B. Place the client in semi-Fowler's position prior to logrolling.
- C. Place the bed in the lowest position before logrolling the client.
- D. Place a pillow between the client's legs prior to logrolling.
Correct Answer: D
Rationale: A pillow maintains spinal alignment during logrolling post-laminectomy.