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The nurse is assisting an older adult client who has problems with constipation and reports fear of defecation because of painful hemorrhoids, to establish a regular bowel pattern. Which action should the nurse take?
- A. Suggest using a stool softener.
- B. Recommend a daily laxative.
- C. Obtain a stool specimen.
- D. Discuss oral analgesic options.
Correct Answer: A
Rationale: Stool softeners ease defecation, reducing hemorrhoid pain.
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The nurse is preparing a client placed on droplet precautions for transport from the client's room to another department. The client wears eyeglasses and refuses to remove them while being transported. Which action should the nurse take?
- A. Obtain permission from the nursing supervisor to transport the client without protective equipment.
- B. Place protective goggles over the client's eyeglasses after first positioning the face mask.
- C. Instruct the client about the need to wear a fitted respirator-style mask when leaving the room.
- D. Secure a surgical face mask over the bridge of the client's nose just below the eyeglasses.
Correct Answer: D
Rationale: Surgical mask ensures droplet precaution compliance.
The nurse has agreed to serve as a client's advocate at the meeting of the hospital ethics committee, which was called to address an ethical dilemma involving the client. To successfully represent the client, what action is essential for the nurse to take?
- A. Develop self-awareness of the nurse's personal values to avoid imposing these values on the client.
- B. Challenge members of the healthcare team whose opinions differ from the wishes of the client.
- C. Educate the client about current nursing literature findings related to the client's ethical dilemma.
- D. Listen to the ethics committee discussions and then inform the client what actions should be taken.
Correct Answer: A
Rationale: Self-awareness prevents bias in advocacy.
An older adult client is admitted to the medical unit following a fall at home. While undressing the client, the nurse observes that the client is wearing an adult diaper and skin breakdown is obvious over the sacral area. Which action should the nurse implement first?
- A. Apply a barrier ointment to intact areas that may be exposed to moisture.
- B. Determine the size and depth of skin breakdown over the sacral area.
- C. Complete a functional assessment of the client's self-care abilities.
- D. Establish a toileting schedule to decrease episodes of incontinence.
Correct Answer: B
Rationale: Assessing breakdown severity guides treatment planning.
The nurse is performing a routine dressing change for a client with a stage 3 pressure ulcer that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?
- A. Leave the dressing off until consulting with the healthcare provider.
- B. Apply a hydrocolloidal gel dressing.
- C. Replace the gauze with a transparent dressing.
- D. Increase the frequency of the dressing changes.
Correct Answer: B
Rationale: Hydrocolloidal dressing promotes healing in granulating wounds.
Which explanation is best for the nurse to provide a client who asks the purpose of using the log rolling technique for turning?
- A. The technique is intended to maintain straight spinal alignment.
- B. Working together can decrease the risk of back injury to the nurses.
- C. Using two or three people increases client safety.
- D. Turning instead of pulling reduces the likelihood of skin damage.
Correct Answer: A
Rationale: Log rolling maintains spinal alignment for safety.