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The nurse observes that a client on a clear liquid diet has a cup of coffee on the breakfast tray. Which action should the nurse implement?
- A. Remove the coffee from the tray, advising the client that it is not included in the diet.
- B. Determine which member of the nursing staff brought the cup of coffee to the client.
- C. Remind the client that no milk or creamer can be added to the coffee.
- D. Consult with the dietician to learn if the client is allowed to drink coffee.
Correct Answer: C
Rationale: Black coffee is allowed without additives.
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The healthcare provider prescribes cefixime oral suspension 200 mg by mouth twice a day for an older adult who has difficulty swallowing pills. The bottle is labeled, 'Cefixime for Oral Suspension, USP 100 mg per 5 mL.' How many mL should the nurse administer daily? (Enter numerical value only.)
Correct Answer: 20
Rationale: 200 mg/dose × 2 doses = 400 mg/day; 400 mg ÷ (100 mg/5 mL) = 20 mL/day.
The nurse plans to encourage a group of young adult clients to engage in problem-solving strategies. Which action is most useful for the nurse to include during the teaching session?
- A. Incorporate verbal analogies.
- B. Offer positive reinforcement.
- C. Provide physical demonstrations.
- D. Use simulation activities.
Correct Answer: D
Rationale: Simulations engage active problem-solving.
The nurse is assisting an older adult client who has problems with constipation and reports fear of defecation because of painful hemorrhoids, to establish a regular bowel pattern. Which action should the nurse take?
- A. Suggest using a stool softener.
- B. Recommend a daily laxative.
- C. Obtain a stool specimen.
- D. Discuss oral analgesic options.
Correct Answer: A
Rationale: Stool softeners ease defecation, reducing hemorrhoid pain.
Twelve hours following a unilateral total knee replacement, a client reports being unable to sleep because of severe incisional pain. What is the best initial nursing action?
- A. Instruct the client in use of the prescribed patient-controlled analgesia (PCA) pump.
- B. Assist the client in assuming a lateral recumbent position for comfort.
- C. Initiate continuous passive motion (CPM) to relieve muscle spasms.
- D. Apply ice to the incision for twenty minutes prior to joint flexion exercises.
Correct Answer: A
Rationale: PCA pump allows self-administered analgesia for immediate pain relief.
The home health nurse is reviewing the personal care needs of an older adult client who lives alone. What client assessment finding(s) indicate(s) the need to assign an unlicensed assistive personnel (UAP) to provide routine foot care and file the client's toenails? Select all that apply.
- A. Hand tremors.
- B. Shuffling gait.
- C. Urinary incontinence.
- D. Diminished visual acuity.
- E. Syncope when bending.
Correct Answer: A,B,D
Rationale: Tremors, gait issues, and poor vision impair safe foot care.