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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 the height of my walker adjusted so lean slightly forward
- 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 my elbows slightly bent when I grasp the walker
Correct Answer: D
Rationale: Slightly bent elbows ensure proper posture and control with a walker.
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A nurse is inserting an indwelling urinary catheter for a male client. After inserting the catheter 15 cm (6 in), the nurse feels resistance and no urine flows through the catheter. Which of the following actions should the nurse take?
- A. Apply lidocaine gel to the urethra.
- B. Inflate the catheter's balloon.
- C. Lower the penis to a 45° angle.
- D. Twist the catheter gently.
Correct Answer: C
Rationale: Lowering the penis aligns the urethra, reducing resistance.
A nurse is preparing to perform a fecal occult blood test of stool specimens for a client. Which of the following actions should the nurse plan to take?
- A. Ensure that the stool specimen does not contain urine.
- B. Repeat the test three times using the same stool specimen.
- C. Have the client defecate into a bedpan that contains a small amount of water.
- D. Wear sterile gloves when handling the stool specimen
Correct Answer: A
Rationale: Urine can contaminate the specimen and affect test accuracy.
A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?
- A. Add 0.5 mL of diluent to the medication.
- B. Inject air into the ampule prior to drawing the medication into a syringe.
- C. Use a filter needle to aspirate the medication.
- D. Cleanse the tip of the ampule with an alcohol swab after opening.
Correct Answer: C
Rationale: A filter needle prevents glass particles from being drawn into the syringe from the ampule.
A nurse is collecting data from a client about bowel elimination. Which of the following statements by the client indicates a risk for impaired bowel elimination?
- A. I drink an average of 2,000 milliliters of water daily.
- B. I take a prescribed opioid pain medication at bedtime.
- C. I love to eat apples and black-eyed peas.
- D. I drink two hot cups of coffee each morning.
Correct Answer: B
Rationale: Opioids can cause constipation, impairing bowel elimination.
A nurse is caring for a client who has a new prescription for a belt restraint. Which of the following actions should the nurse take?
- A. Make sure four fingers fit between the restraint and the client's body.
- B. Apply the belt restraint over the client's gown.
- C. Check the client's skin integrity every 4 hr.
- D. Tie the belt restraint to the side rail of the bed.
Correct Answer: B
Rationale: Applying over the gown prevents skin irritation and ensures proper fit.