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The nurse is caring for an elderly client after hip replacement surgery. The client is distressed because he has not had a bowel movement in 3 days. Which action by the nurse would be most appropriate?
- A. Administer the prescribed as-needed milk of magnesia
- B. Ask dietary services to add more fruits and vegetables to the client’s tray
- C. Notify the registered nurse
- D. Perform a focused abdominal assessment
Correct Answer: D
Rationale: A focused abdominal assessment determines the cause of constipation (e.g., impaction, obstruction) before interventions like laxatives, dietary changes, or RN notification, ensuring safe and targeted care.
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While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child's developmental needs?
- A. I want to protect my child from any falls.'
- B. I will set limits on exploring the house.'
- C. I understand our child's need to use those new skills.'
- D. I intend to keep control over our child's behavior.'
Correct Answer: C
Rationale: I understand our child's need to use those new skills.' Erikson describes the stage of the toddler as being the time when there is normally an increase in autonomy. The child needs to use motor skills to explore the environment.
The nurse is assessing a client who had a left arm cast applied four hours ago. Which finding indicates that the client may have circulatory impairment?
- A. The client's nail beds blanch when the nurse applies pressure; color returns in two seconds.
- B. The client's fingers on the left hand are cold to the touch.
- C. The client complains of pain at the fracture site.
- D. The client is unable to move the fingers on the left hand.
Correct Answer: B
Rationale: Cold fingers suggest impaired circulation in the casted arm, indicating potential compartment syndrome or vascular compromise, requiring immediate evaluation. Normal blanching, fracture pain, or immobility are less specific.
What nursing action is essential when oxygen is ordered for a client who is living at home?
- A. Assist the client and family in checking all electrical appliances in the vicinity for frayed cords.
- B. Encourage the client and family to purchase fire extinguishers.
- C. Remove electrical devices from the room where oxygen is in use.
- D. Encourage the client and family to carpet the client's room.
Correct Answer: A
Rationale: Checking for frayed cords reduces fire risk, as oxygen supports combustion. Extinguishers are secondary, removing devices is impractical, and carpeting increases static sparks.
The nurse is reinforcing teaching about foot care for a group of clients with diabetes mellitus. Which of the following information should the nurse include? Select all that apply.
- A. Dry the feet vigorously with a towel after bathing
- B. Use an over-the-counter kit to treat corns and calluses
- C. Use cotton or lamb’s wool to separate overlapping toes
- D. Wash the feet with lukewarm water
- E. Wear hard-sole shoes and do not go barefoot
Correct Answer: C,D,E
Rationale: Using cotton/wool for toes prevents pressure sores, lukewarm water avoids burns, and hard-sole shoes protect feet. Vigorous drying risks skin breakdown, and over-the-counter kits can cause injury in diabetic feet with poor sensation.
The nurse working in an extended care facility transcribes a prescription from the health care provider for a single daily dose of 150 mg of ranitidine; this is to be taken orally at bedtime for treatment of gastroesophageal reflux disease. Of the following prescriptions, which one is transcribed correctly?
- A. Ranitidine 150 mg daily by mouth
- B. Ranitidine 150 mg per os qhs
- C. Ranitidine 150 mg po qd nightly
- D. Ranitidine 150 mg PO at bedtime
Correct Answer: D
Rationale: Ranitidine 150 mg PO at bedtime accurately specifies the dose, route, and timing (qhs = at bedtime). Other options are less precise or redundant (e.g., ‘qd nightly’).