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An 87-year-old client has been admitted to the hospital with signs and symptoms of a urinary tract infection along with agitation, confusion, and disorientation to time and place. What is the most important nursing action?
- A. Encouraging frequent fluid intake
- B. Keeping the bed elevated and side rails raised
- C. Providing one-on-one supervision
- D. Turning the lights off in the client's room
Correct Answer: C
Rationale: One-on-one supervision (C) ensures safety for a confused, agitated client at risk for falls or harm. Fluids (A), side rails (B), and dim lights (D) are secondary or inappropriate.
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The nurse is caring for a client who is receiving antibiotic therapy and develops Clostridioides difficile colitis. Which of the following infection-control precautions should the nurse implement? Select all that apply.
- A. Disinfect surfaces using a diluted bleach solution
- B. Perform hand hygiene using an alcohol-based hand sanitizer
- C. Wear a face mask
- D. Wear a protective gown
- E. Wear nonsterile gloves
Correct Answer: A,D,E
Rationale: Bleach disinfection (A), gowns (D), and gloves (E) are required for C. difficile, which is spore-forming. Alcohol sanitizers (B) are ineffective against spores, and masks (C) are not routinely needed.
The nurse is reinforcing teaching to parents about childhood nutrition and feeding practices. The nurse recognizes that which snack is best for a toddler?
- A. 1/2 cup orange juice
- B. Dry, sweetened cereal
- C. Raw carrot sticks
- D. Slice of cheese
Correct Answer: D
Rationale: A slice of cheese (D) is a nutrient-dense, easy-to-chew snack suitable for a toddler, providing protein and calcium. Orange juice (A) is high in sugar, sweetened cereal (B) lacks nutritional value, and raw carrot sticks (C) pose a choking hazard.
The charge nurse in a long-term memory care facility is making assignments for the Alzheimer unit. Which tasks may be delegated to experienced unlicensed assistive personnel? Select all that apply.
- A. Assisting clients with bathing and hair care
- B. Evaluating safety hazards in clients' rooms
- C. Monitoring clients for behavioral changes
- D. Placing bed alarms at night for clients at risk for wandering
- E. Reporting a client's swallowing difficulties during mealtime
Correct Answer: A,D,E
Rationale: Bathing/hair care (A), placing bed alarms (D), and reporting swallowing issues (E) are within UAP scope. Evaluating hazards (B) and monitoring behavior changes (C) require nursing judgment.
An adult had a thyroidectomy under local anesthesia and is now in the postanesthesia care unit. Which finding is of most concern to the nurse?
- A. The client complains of a sore throat.
- B. The client's hand involuntarily clenches when the nurse checks the blood pressure.
- C. The client is sitting upright in the bed.
- D. The client asks for a drink of water.
Correct Answer: B
Rationale: Involuntary hand clenching (Trousseau's sign) suggests hypocalcemia from parathyroid damage during thyroidectomy, a serious complication requiring immediate attention. Sore throat, upright position, or thirst are less urgent.
A male client calls for a nurse because of chest pain. Which statement by the client would require the most immediate action by the nurse?
- A. When I take in a deep breath, it stabs like a knife.'
- B. The pain came on after dinner. That soup seemed very spicy.'
- C. When I turn to the left, it feels like my heart is being squeezed.'
- D. The pain radiates to my jaw and left arm.'
Correct Answer: D
Rationale: Chest pain radiating to the jaw and left arm is a classic symptom of myocardial infarction, requiring immediate action to assess for a life-threatening cardiac event.