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A nurse is collecting data from a client who has depression to identify his ability to perform activities of daily living (ADLs) prior to discharge. Which of the following data should the nurse collect?
- A. Ability to perform oral hygiene
- B. Ability to bathe himself
- C. Ability to identify how often he should schedule his car for an oil change
- D. Ability to balance his bank account
- E. Ability to dress himself
Correct Answer: A,B,E
Rationale: Assessing ADLs includes evaluating self-care abilities like hygiene, bathing, and dressing.
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A nurse is caring for an older adult client who has constipation. Which of the following actions should the nurse take?
- A. Request that the provider prescribe a stool softener.
- B. Promote active range-of-motion activities.
- C. Add fluid and fiber to the diet.
- D. Avoid gas-producing foods.
Correct Answer: C
Rationale: The correct answer is C: Add fluid and fiber to the diet. Increasing fluid intake helps soften the stool, making it easier to pass. Fiber adds bulk to the stool, promoting regular bowel movements. This is a non-invasive and effective intervention for constipation in older adults. Requesting a stool softener (A) may be considered if dietary interventions are ineffective. Promoting active range-of-motion activities (B) may help prevent constipation but is not the first-line intervention. Avoiding gas-producing foods (D) is not directly related to treating constipation.
A nurse is reinforcing preoperative teaching with a client who will undergo abdominal surgery. The nurse explains that the client will wear antiembolism stockings after the procedure. When the client asks what the stockings do, which of the following responses should the nurse make?
- A. They'll protect your legs and heels from skin breakdown.
- B. They'll help keep you warm immediately after your surgery.
- C. They'll improve your circulation to keep blood from pooling in your legs.
- D. They'll make it easier for you to do leg exercises after your surgery.
Correct Answer: C
Rationale: Correct Answer: C. They'll improve your circulation to keep blood from pooling in your legs.
Rationale:
1. Antiembolism stockings apply gentle pressure to the legs, promoting blood flow.
2. Improved circulation helps prevent blood clots by reducing the risk of venous stasis.
3. By preventing blood pooling, the stockings decrease the chances of deep vein thrombosis.
Incorrect Choices:
A. Skin breakdown prevention is not the primary purpose of antiembolism stockings.
B. Keeping warm is not the main function of these stockings.
D. While leg exercises are important post-surgery, it is not the main reason for using antiembolism stockings.
A nurse in an urgent care clinic is preparing to remove skin sutures from a client. Which of the following actions should the nurse take?
- A. Remove loose sutures first
- B. Cut below the suture knot
- C. Use clean bandage scissors
- D. Lift sutures from the skin with a sterile needle
Correct Answer: B
Rationale: Cutting below the suture knot prevents external contamination and reduces infection risk.
A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following adventitious lung sounds?
- A. Crackles
- B. Rhonchi
- C. Stridor
- D. Wheezes
Correct Answer: D
Rationale: Wheezes are high-pitched musical sounds heard on expiration and indicate narrowed airways, commonly found in asthma patients.
A nurse is assisting with the care of a client who has developed cardiogenic shock. When evaluating circulation to the client's brain, which of the following pulse sites should the nurse use?
- A. Femoral
- B. Carotid
- C. Popliteal
- D. Radial
Correct Answer: B
Rationale: The correct answer is B: Carotid. The carotid pulse site should be used when assessing circulation to the brain in a client with cardiogenic shock because it is the closest pulse site to the brain. The carotid artery supplies blood directly to the brain, making it the most accurate site to assess perfusion to this vital organ.
A: Femoral, C: Popliteal, and D: Radial are not ideal pulse sites for assessing circulation to the brain in a client with cardiogenic shock because they are further away from the brain compared to the carotid artery. Using these sites may not provide an accurate representation of cerebral perfusion in this critical situation.