Nokea
The nurse is explaining perineal care to the caregiver of a male client. Which information should the nurse include?
- A. Dizziness can occur during cleansing.
- B. The pubic area should be kept shaved.
- C. The foreskin should not be retracted.
- D. An erection may occur while providing care.
Correct Answer: D
Rationale: Reflex erection is normal and should be explained.
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A client with a sprained ankle is seen at the clinic and is given a pair of crutches. When the client stands with the aid of the crutches, the nurse notes a space of three finger widths between the top of the crutch and the client's axilla. Which action should the nurse take?
- A. Confer with the physical therapist for correct crutch size.
- B. Ask the client to sit down while the crutch length is adjusted.
- C. Assess the client for signs of diminished circulation in the hands.
- D. Proceed with teaching the client how to walk with the crutches.
Correct Answer: D
Rationale: Three-finger gap indicates proper fit.
The nurse observes an unlicensed assistive personnel (UAP) providing care for two clients using the same gloves. Which action should the nurse take first?
- A. Praise the UAP for using standard precautions.
- B. Instruct the UAP to change gloves immediately.
- C. Request that an in-service program be scheduled on asepsis.
- D. Submit an adverse occurrence report to the unit manager.
Correct Answer: B
Rationale: Changing gloves prevents cross-contamination.
The healthcare provider prescribes magnesium hydroxide 4,800 mg PO at bedtime for a patient with constipation. The bottle is labeled, 'Magnesium Hydroxide Saline Laxative, USP 400 mg per 5 mL'. How many ounces should the nurse instruct the patient to take with each dose? (Enter numerical value only.)
Correct Answer: 2
Rationale: 4,800 mg ÷ (400 mg/5 mL) = 60 mL = 2 oz.
The nurse notes that a client has cyanosis of the toes and fingertips. Which vital sign should the nurse obtain first?
- A. Heart rate.
- B. Blood pressure.
- C. Temperature.
- D. Respiratory rate.
Correct Answer: D
Rationale: Respiratory rate assesses hypoxia.
A client is admitted with pneumonia and has a recent history of methicillin-resistant Staphylococcus aureus (MRSA). The client is placed in isolation. When caring for the client, which item should the nurse place in a designated biohazard bag before it is removed from the room?
- A. Stethoscope.
- B. Bed linens.
- C. Sputum specimen.
- D. Paper mask and gown.
Correct Answer: D
Rationale: Disposable PPE prevents contamination.