The nurse performs a head-to-toe assessment on an assigned c...

The nurse performs a head-to-toe assessment on an assigned client. Which of the following client findings are examples of subjective data? Select all that apply.

A. The client reports feeling nauseated.
B. The client's lower extremities are swollen.
C. The client expresses nervousness about test results.
D. The client reports that their leg is itching.
E. The client rates pain at a 6 on a scale of 1 to 10.
F. The client vomits twice after eating dinner.

Correct Answer: A,C,D,E

Rationale: Subjective data are client-reported, like nausea, nervousness, itching, and pain rating. Swelling and vomiting are objective, observed by the nurse.

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The nurse observes a student inserting an indwelling urinary catheter into a female client. Which action by the student requires follow-up by the nurse? The student

A. Applies clean gloves to cleanse the perineal area with soap and water.
B. Asks the client to bear down as the catheter is slowly inserted through the urethral meatus.
C. Separates the labia with the fingers of the dominant hand when cleaning with antiseptic solution.
D. Secures the catheter tubing to the inner thigh.
E. Attaches the drainage bag to the side rails of bed.

Correct Answer: A,C,E

Rationale: Sterile gloves are required for perineal cleaning, the non-dominant hand holds the labia, and the drainage bag should be attached below the bladder level, not to side rails. Bearing down and securing to the inner thigh are correct.

The nurse is observing infection control practices in the nursing unit. Which of the following findings requires follow-up? Select all that apply.

A. Doors kept closed for clients with contact precautions
B. Gloves being worn by staff to pass meal trays
C. Disposable dishes being used for clients on isolation precautions
D. Bedside fan being removed from a room with negative pressure
E. Alcohol-based hand sanitizers for a client with C. diff

Correct Answer: B,E

Rationale: Gloves are not required for passing meal trays unless direct contact with infectious material is anticipated. Alcohol-based sanitizers are ineffective against C. difficile; soap and water are required.

The nurse observes a fire in a client's room. The nurse should take which initial action?

A. Rescue the client
B. Extinguish the fire
C. Activate the fire alarm
D. Place a linen blanket over the fire

Correct Answer: A

Rationale: Per the RACE protocol, rescuing the client is the initial action to ensure safety.

A health care provider (HCP) orders the immediate use of a piece of electrical care equipment for a client. When the nurse goes to use the piece of equipment, the nurse immediately suspects it may be faulty. The nurse should take which initial action?

A. Try the piece of electrical care equipment and see if it becomes hazardous.
B. Call the health care provider and report your suspicion.
C. Ask the client if they want you to try the piece of electrical care equipment.
D. Immediately remove the piece of electrical care equipment from service.

Correct Answer: D

Rationale: Removing faulty equipment from service prevents harm, the priority action. Trying it, consulting the client, or calling the provider delays safety measures.

The nurse is caring for a client immediately following hypophysectomy. The nurse should position the client

A. Trendelenburg
B. Side-lying
C. high-Fowler's
D. Reverse Trendelenburg

Correct Answer: C

Rationale: High-Fowler’s position (head elevated 30–45 degrees) is recommended post-hypophysectomy to reduce intracranial pressure and prevent cerebrospinal fluid leakage. Trendelenburg and reverse Trendelenburg could increase pressure or disrupt surgical site healing, and side-lying is less effective for this purpose.