Nokea
The nurse is transferring a client from a wheelchair to the bed. Which is the correct procedure?
- A. Pull the client toward you, and pivot him on the unaffected limb
- B. Pull the client toward you, and pivot him on the affected limb
- C. Push the client toward the bed, and pivot him on the affected limb
- D. Stand the client on both legs, and push him toward the bed
Correct Answer: A
Rationale: Pulling the client and pivoting on the unaffected limb ensures safety and leverages the client's stronger side for support.
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Mr. H. is upset regarding being in the hospital for another day because he states it costs too much. The rights he is likely to demand include all of the following except:
- A. the right to examine and question the bill
- B. the right to reasonable response to requests
- C. the right to refuse treatment
- D. the right to confidentiality
Correct Answer: D
Rationale: The client's concern about costs suggests he may demand to examine the bill, expect reasonable responses, or refuse treatment. Confidentiality, while a right, is unrelated to his stated financial concerns and is not suggested to be breached.
Ms. Petty is having difficulty falling asleep. Which of the following measures promote sleep?
- A. exercising vigorously for 20 minutes each night beginning at 9:30 p.m.
- B. taking a cool shower and drinking a hot cup of tea
- C. watching TV nightly until midnight
- D. getting a back rub and drinking a glass of warm milk
Correct Answer: D
Rationale: A back rub and warm milk promote relaxation and sleep. Vigorous exercise, cool showers, hot tea, and late TV watching are stimulating and disrupt sleep.
Perineal care to a female client by the nurse can be performed:
- A. Without gloves, pouring water from a sterile bottle
- B. Without gloves, having the client perform all care
- C. With gloves, washing the perineal area from front to back
- D. With gloves, washing the perineal area from back to front
Correct Answer: C
Rationale: Perineal care requires gloves and washing from front to back to prevent bacterial contamination of the urethra, ensuring infection control.
A pregnant client has congenital heart disease. The nurse should expect to see which alterations in this client's diet during pregnancy?
- A. reduced calories and reduced fat
- B. caffeine and sodium restrictions
- C. decreased protein and increased complex carbohydrates
- D. fluid restriction and reduced calories
Correct Answer: B
Rationale: Caffeine and sodium restrictions are necessary to reduce cardiac strain and fluid retention in a pregnant client with heart disease, avoiding exacerbation of her condition.
The client with an indwelling urinary catheter requires discharge teaching. Which interventions should the nurse include in the teaching plan? Select all that apply.
- A. Plan to change the urinary catheter once a week.
- B. Cleanse the perineal area daily with soap and water.
- C. Secure the catheter tubing to the thigh with tape.
- D. Avoid showering while the catheter is in place.
- E. Perform hand hygiene before and after catheter care.
Correct Answer: B,C,E
Rationale: B: Daily cleansing with soap and water prevents infection. C: Securing the catheter reduces trauma. E: Hand hygiene minimizes infection risk. A: Monthly changes are recommended unless blockage occurs. D: Showering is safe if the client's condition allows.