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The nurse is teaching a spouse how to care for a client who recently had a stroke and has residual weakness on the right side. Which style of shoes should the nurse recommend the client wear when ambulating with the spouse's assistance?
- A. Slip-on rubber shower shoes
- B. Tennis shoes with Velcro
- C. Leather-soled loafers
- D. Rubber-soled slippers
Correct Answer: B
Rationale: Velcro shoes provide support and ease of use.
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The mother of a child born with Tetralogy of Fallot asks the nurse, 'Why did this happen to my baby? What did I do wrong?' Which response by the nurse is most helpful?
- A. Is there any particular reason why you think this is your fault?
- B. With surgery, your baby should have a full recovery.
- C. This must be a very difficult time for you.
- D. You did nothing wrong.
Correct Answer: C
Rationale: Empathy validates emotional distress.
The nurse is assessing a client's pain experience. Which nursing intervention is most effective in determining the severity of a client's pain?
- A. Review the client's medical history and admission assessment.
- B. Compare the client's current vital signs to the admission baseline.
- C. Note how frequently doses of analgesics have been administered.
- D. Ask the client to describe the intensity of the pain being experienced.
Correct Answer: D
Rationale: Client self-report is the gold standard for pain severity.
The nurse receives a new prescription to administer oxygen at 3 L/minute via nasal cannula to maintain an oxygen saturation between 90 and 100% for a client. The nurse obtains an oxygen saturation reading of 85%, and after repositioning the oximeter on a different finger, obtains a second reading of 87%. Which action should the nurse take next?
- A. Place the client in a Trendelenburg position.
- B. Securely place the prongs of the cannula in the nostrils.
- C. Place the pulse oximeter on the client's earlobe.
- D. Document the second reading in the client's record.
Correct Answer: B
Rationale: Proper cannula placement ensures oxygen delivery.
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.
When conducting diet teaching for a client who is on a postoperative clear liquid diet, which foods should the nurse encourage the client to consume?
- A. Oatmeal, cream of wheat, pureed liquid.
- B. Pureed beans, liquid protein supplements, milkshake.
- C. Pureed carrots, creamed soup, ice cream.
- D. Carbonated drinks, gelatin, broth.
- E. Water, tea, ice chips.
Correct Answer: D,E
Rationale: Clear liquids are transparent and easily digested.