Nokea
A nurse is reviewing the laboratory reports of four clients. Which of the following clients should the nurse expect to have a positive fecal occult blood test?
- A. A client who has ulcerative colitis.
- B. A client who has cholecystitis.
- C. A client who uses laxatives.
- D. A client who has stomatitis.
Correct Answer: A
Rationale: Ulcerative colitis causes colon bleeding, leading to a positive test.
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A nurse is showing a newly licensed nurse how to use a mechanical lift. Which of the following statements by the newly licensed nurse indicates an understanding of this assistive device?
- A. The sides of the sling are for the client to hold on to.
- B. This type of device is useful for a client who cannot assist.
- C. The lower end of the sling goes below the client's calves.
- D. The device requires the client to use upper body strength.
Correct Answer: B
Rationale: Mechanical lifts aid clients unable to assist, ensuring safe transfers.
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.
A nurse is reinforcing teaching with a client who has crutches regarding the use of the three-point gait. Which of the following instructions should the nurse include?
- A. Stand with the crutch tips against the feet.
- B. Bear weight on the unaffected leg.
- C. Keep the crutches at the level of the axillae.
- D. Hold the arms straight when walking.
Correct Answer: B
Rationale: Weight on the unaffected leg is key to the three-point gait for stability.
A home health nurse is visiting a client who has advanced Alzheimer's disease. The client's partner states, 'I miss being able to go places with my friends.' Which of the following is an appropriate response by the nurse?
- A. We can discuss this when you're not feeling overwhelmed.
- B. Have you tried taking your partner with you when you go out?
- C. Tell me more about your expectations.
- D. I understand how you feel. I've had a relative go through the same thing.
Correct Answer: C
Rationale: Asking about expectations opens dialogue and shows empathy, supporting the partner's needs.
A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about the proper use of restraints. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
- A. Pad bony prominences before applying a restraint.
- B. Tie the ends of the restraint to the client's bed rail.
- C. Use a square knot to secure the client's restraint to the bed.
- D. Observe the client's skin integrity every 2 hr.
- E. Ensure that 2 fingers can be placed between the restraint and the client.
Correct Answer: A,D,E
Rationale: A: Prevents skin breakdown. D: Ensures early detection of issues. E: Ensures proper fit and circulation.