Nokea
A nurse is supervising an assistive personnel (AP) who is applying antiembolic stockings for a client. Which of the following actions by the AP requires intervention by the nurse?
- A. Asking the client to point their toes before applying the stockings
- B. Ensuring that creases in the stockings are on the front of the client's legs
- C. Turning the stockings inside out before applying them
- D. Applying the stockings before the client gets out of bed
Correct Answer: B
Rationale: Creases should be avoided to prevent skin irritation; this requires intervention.
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A nurse is performing nasopharyngeal suctioning for an adult client. Which of the following techniques should the nurse use?
- A. Apply suction while inserting the catheter
- B. Apply intermittent suction for 30 seconds
- C. Insert the catheter 10 cm (4 in)
- D. Wait 1 min between suctioning attempts
Correct Answer: D
Rationale: Waiting 1 minute between attempts allows oxygenation and prevents hypoxia.
The client has mild hypertension.
A nurse is reinforcing teaching about healthy lifestyle changes with a female client who has mild hypertension. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should exercise for 15 minutes two times per week.
- B. I should decrease my salt intake to 2 grams per day.
- C. I will set my blood pressure goal at 130 over 84.
- D. I can have two glasses of wine with dinner.
Correct Answer: B
Rationale: Reducing salt to 2 grams daily helps manage hypertension, showing understanding.
A nurse is contributing to the plan of care for a client who is experiencing a herpes simplex outbreak. Which of the following interventions should the nurse recommend?
- A. Administer an antibiotic medication.
- B. Cleanse skin eruptions with povidone-iodine.
- C. Avoid over-the-counter topical ointments.
- D. Place disposable thermometers in the client's room.
Correct Answer: C
Rationale: Avoiding OTC ointments prevents irritation or delayed healing in herpes simplex outbreaks.
A nurse in an acute care setting is assisting in collecting client information to include in a referral for a physical therapist. Which of the following information should the nurse plan to include?
- A. Family medical history
- B. Medications taken prior to admission
- C. Physical assessment findings
- D. Medical health insurance claim
Correct Answer: C
Rationale: Physical assessment findings inform the therapist's treatment plan.
A nurse is caring for a preschooler who recently experienced the death of a parent. Which of the following findings should the nurse identify as consistent with this age group?
- A. Believes the death is punishment for bad behavior
- B. Understands that everyone dies eventually
- C. Recognizes the parent will never wake up
- D. Expresses curiosity about the funeral service
Correct Answer: A
Rationale: Preschoolers often view death as punishment due to magical thinking.