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A nurse is reinforcing teaching with a client who is perimenopausal. Which of the following statements by the client indicates an understanding of the teaching?
- A. I might have headaches due to a decline in my estrogen levels.
- B. I should stop receiving Papanicolaou tests once I reach menopause.
- C. I can expect to have regular periods until I am in menopause.
- D. The best time to perform a breast self-examination is on the first day of my period.
Correct Answer: A
Rationale: Declining estrogen can cause headaches, reflecting perimenopause symptoms.
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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. Turn the client every 4 hours.
- C. Cleanse the perineal area with povidone-iodine solution.
- D. Place a moisture barrier ointment over the perineal area.
Correct Answer: D
Rationale: Moisture barrier ointment protects skin from breakdown due to fecal exposure.
A nurse is preparing to administer sucralfate 80 mg/kg/day to divide into four doses per day to a child who weighs 35 kg. The amount available is sucralfate oral suspension 1 g/10 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 7 mL
Rationale: 35 kg × 80 mg/kg/day = 2800 mg/day; 2800 mg ÷ 4 = 700 mg/dose; 700 mg ÷ (1000 mg/10 mL) = 7 mL/dose.
A nurse is preparing to clean a blood spill on a bedside table. Which of the following solutions should the nurse plan to use?
- A. Isopropyl alcohol.
- B. Hydrogen peroxide.
- C. Chlorhexidine gluconate.
- D. Chlorine bleach.
Correct Answer: D
Rationale: Chlorine bleach effectively kills bloodborne pathogens like HIV and hepatitis B.
A nurse in a long-term care facility is caring for a client who has a tracheostomy. Which of the following actions should the nurse take?
- A. Apply suction while inserting the catheter.
- B. Apply intermittent suction for up to 30 seconds.
- C. Preoxygenate the client prior to suctioning.
- D. Instruct the client to swallow during catheter insertion.
Correct Answer: C
Rationale: Preoxygenation prevents hypoxia during suctioning, enhancing safety.
A nurse is assisting in the care of a client who has pneumonia in the medical unit. Which of the following information should the nurse include in discharge teaching for the client? (Select all that apply)
- A. Take antibiotics for 10 days.
- B. Ensure the oxygen delivery system is at least 8 feet from any heat source.
- C. Decrease the steroid dose each day.
- D. Take antibiotic medication with or without food.
- E. Adjust the oxygen flow rate as needed to ease breathing.
- F. Take steroid medication in the morning.
Correct Answer: A,B,D,F
Rationale: A: Ensures full treatment course. B: Reduces fire hazard. D: Flexibility aids compliance. F: Morning dosing minimizes sleep disruption.