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The nurse works on a medical-surgical unit and is responsible for assessing the client's vital signs. Which of the following clients can have their temperature measured orally? Select all that apply.
- A. A 61-year-old woman who had oral surgery
- B. A 44-year old man with chest pain on oxygen via nasal canula
- C. An 83-year-old woman with diarrhea
- D. A 29-year-old client with an earache
- E. A 6-year-old client with a sore throat and difficulty swallowing
Correct Answer: B,C,D
Rationale: Oral temperature is safe for clients with chest pain, diarrhea, or earache, as they have no oral contraindications. Oral surgery and difficulty swallowing contraindicate oral measurement.
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The nurse is caring for a client with an indwelling urethral catheter. Which of the following actions should the nurse take? Select all that apply.
- A. Empty drainage bag when 1/2 full.
- B. Provide perineal hygiene using mild soap and hot water.
- C. Ensure tubing is clipped onto the edge of the linens.
- D. Wear sterile gloves while cleaning the urinary meatus.
- E. Clean catheter starting at meatus and moving downward while holding it securely.
Correct Answer: A,E
Rationale: Emptying the bag when half full prevents reflux, and cleaning from the meatus downward avoids contamination. Hot water is too harsh, clipping tubing risks tension, and clean gloves suffice for cleaning.
Upon entering a client's room, the nurse finds the client lying on the floor. What is the first action the nurse should implement?
- A. Call for help to get the client back in bed
- B. Assist the client back to bed
- C. Establish if the client is responsive
- D. Ask the client what happened
Correct Answer: C
Rationale: Establishing responsiveness ensures the client’s immediate safety and guides further actions. Other steps follow after assessing the client’s condition.
The following scenario applies to the next 1 items
Item 1 of 1
Nurses' Notes
Orders Current Medications Laboratory>
1700: 73-year-old male reports explosive, watery, foul-smelling diarrhea that started two days ago. The client reports intermittent abdominal cramping that occurs with watery diarrhea. He says his wife made him come in to get medical attention because he was starting to 'feel weak' and 'probably dehydrated.' The client was assessed to have: a sunken eye appearance, dry, flaky skin, and thready peripheral pulses. VS: Oral Temperature 98° F (36.7° C), pulse 86/minute, respirations 16/minute, blood pressure 113/68 mm Hg, oxygen saturation 96% on room air.
1725: Stool sample of foul-smelling diarrhea sent to the lab.
1830: Laboratory result received. Physician notified of results.
The nurse reviews the nurses' notes, orders, current medications, and laboratory data for a 73-year-old male with explosive, watery, foul-smelling diarrhea. Based on the clinical data, select five (5) nursing interventions the nurse should implement.
- A. Obtain a prescription for metronidazole
- B. Place a droplet precautions sign outside the room
- C. Educate the client to wash surfaces at home with bleach
- D. Remove the alcohol-based sanitizers from the room
- E. Request a prescription for a cleansing enema
- F. Encourage the intake of by mouth (PO) fluids
- G. Review hand hygiene measures with the client
Correct Answer: A,C,D,F,G
Rationale: Suspected C. difficile requires metronidazole, bleach cleaning, removal of alcohol-based sanitizers, fluid intake encouragement, and hand hygiene education. Droplet precautions and enemas are not indicated.
The home health nurse is caring for a 67-year-old female client with progressive multiple sclerosis.
Item 4 of 6
Current Medications
Nurses' Notes
• cephalexin 500 mg p.o. every six hours for 10 days
• diazepam 5 mg p.o. daily PRN muscle spasm
• multivitamin 1 tablet daily
• ergocalciferol 10,000 international units p.o. Daily
For each potential intervention, click to specify whether the intervention is indicated or not indicated for the client with progressive multiple sclerosis.
- A. Obtain a referral for occupational therapy for fatigue and energy conservation training
- B. Promote rest by encouraging daytime napping over consistent nighttime sleep
- C. Encourage the client to walk to the mailbox at midday for sun exposure
- D. Instruct the client to increase fluid intake with caffeinated beverages
- E. Obtain an order for physical therapy for home mobility and coordination evaluation
- F. Educate the client on the early signs of cystitis and the importance of completing antibiotics
- G. Educate the client to wear slippers while walking inside
Correct Answer: A,E,F,G
Rationale: Occupational therapy, physical therapy, cystitis education, and slipper use are indicated to address fatigue, mobility, infection prevention, and fall risk. Daytime napping and midday sun exposure are not indicated due to heat sensitivity and inconsistent sleep.
The nurse is observing a student nurse wash their hands with soap and water. Which observation requires follow-up? The student nurse
- A. washes their hands using warm water.
- B. dries hands thoroughly from wrists to fingers with paper towel.
- C. wets their wrists and hands with fingers pointed downward.
- D. pushes wristwatch and long uniform sleeves above wrists.
Correct Answer: C
Rationale: Fingers should point upward during handwashing to ensure soap and water reach all surfaces effectively.