Nokea
The nurse is caring for a client with left-sided weakness from a stroke. When assisting the client to a chair, what should the nurse do?
- A. Bend at the waist
- B. Keep the feet close together
- C. Pivot on the foot proximal to the chair
- D. Use a transfer belt
Correct Answer: D
Rationale: A transfer belt ensures safety during transfers. Bending at the waist , close feet , and pivoting increase fall risk.
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The nurse is administering hygienic care to an elderly client in her home. What should the nurse wash first?
- A. Perineal area
- B. Face
- C. Upper torso
- D. Hands
Correct Answer: B
Rationale: Washing the face first during hygienic care respects client comfort and dignity, starting with a less invasive area. It also prevents cross-contamination from dirtier areas like the perineum.
The health care provider prescribes phenazopyridine hydrochloride for a client with a urinary tract infection. What would the office nurse remind the client to expect while taking this medication?
- A. Constipation
- B. Difficulty sleeping
- C. Discoloration of urine
- D. Dry mouth
Correct Answer: C
Rationale: Phenazopyridine causes orange-red urine discoloration, a benign effect. Constipation , insomnia , and dry mouth are not typical.
The nurse is talking with a client who has Huntington disease and is considering becoming pregnant. Which of the following statements would be appropriate for the nurse to make?
- A. There are alternative methods to expand your family. You should consider adoption.
- B. Genetic counseling is recommended. You will receive a referral before you leave.
- C. Huntington disease inheritance requires both biological parents to carry the gene.
- D. Huntington disease occurs spontaneously and is not likely to affect your children.
Correct Answer: B
Rationale: Huntington's is autosomal dominant, so genetic counseling is essential. Adoption dismisses the client's wishes, both parents carrying the gene is incorrect, and spontaneous occurrence is false.
The nurse is providing care in the home to a person who has AIDS. Which behavior, if observed by the nurse, indicates a need for further instruction?
- A. The client uses the same dishes as the rest of the family.
- B. The client shares a bathroom with the rest of the family.
- C. The client and his brother use the same razor.
- D. The client often cooks for the family.
Correct Answer: C
Rationale: Sharing razors risks bloodborne HIV transmission, requiring education. Using shared dishes, bathrooms, or cooking poses no significant risk with standard precautions.
The nurse is caring for a client recovering from a fracture. Which diet selection would be best for this client?
- A. Fried chicken, a loaded baked potato, and tea
- B. Dressed cheeseburger, French fries, and soda
- C. Tuna fish salad on sourdough bread, potato chips, and skim milk
- D. Broiled chicken, Mandarin orange salad, and milk
Correct Answer: D
Rationale: A diet rich in protein, calcium, and vitamins supports bone healing. Broiled chicken, Mandarin orange salad, and milk provide these nutrients. Options A, B, and C include less nutrient-dense foods like fried items or chips, making them less ideal.