Which action should the nurse implement when providing wound care instructions to a
client who does not speak English?
A. Ask an interpreter to provide wound care instructions.
B. Speak directly to the client, with an interpreter translating.
C. Request the accompanying family member to translate.
D. Instruct a bilingual employee to read the instructions.
Answer: B
Wound care instructions should be given directly to the client by the nurse
with an interpreter (B) who is trained to provide accurate and objective
translation in the client's primary language, so that the client has the
opportunity to ask questions during the teaching process. The interpreter
usually does not have any health care experience, so the nurse must provide
client teaching (A). Family members should not be used to translate
instructions (C) because the client or family member may alter the instructions
during conversation or be uncomfortable with the topics discussed. The
, employee should be a trained interpreter (D) to ensure that the nurse's
instructions are understood accurately by the client.
A client has a nasogastric tube connected to low intermittent suction. When
administering medications through the nasogastric tube, which action should the nurse
do first?
A. Clamp the nasogastric tube.
B. Confirm placement of the tube.
C. Use a syringe to instill the medications.
D. Turn off the intermittent suction device.
Answer: D
The nurse should first turn off the suction (D) and then confirm placement of
the tube in the stomach (B) before instilling the medications (C). To prevent
immediate removal of the instilled medications and allow absorption, the tube
should be clamped for a period of time (A) before reconnecting the suction.
Urinary catheterization is prescribed for a postoperative female client who has been
unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the
tubing. Which action will the nurse take next?
A. Clamp the catheter and recheck it in 60 minutes.
B. Pull the catheter back 3 inches and redirect upward.
C. Leave the catheter in place and reattempt with another catheter.
D. Notify the health care provider of a possible obstruction.
, Answer: C
It is likely that the first catheter is in the vagina, rather than the bladder.
Leaving the first catheter in place will help locate the meatus when attempting
the second catheterization (C). The client should have at least 240 mL of urine
after 8 hours. (A) does not resolve the problem. (B) will not change the
location of the catheter unless it is completely removed, in which case a new
catheter must be used. There is no evidence of a urinary tract obstruction if
the catheter could be easily inserted (D).
A 65-year-old client who attends an adult daycare program and is wheelchair-mobile
has redness in the sacral area. Which instruction is most important for the nurse to
provide?
A. Take a vitamin supplement tablet once a day.
B. Change positions in the chair at least every hour.
C. Increase daily intake of water or other oral fluids.
D. Purchase a newer model wheelchair.
Give this one a try later!
Answer: B
The most important teaching is to change positions frequently (B) because
pressure is the most significant factor related to the development of pressure
ulcers. Increased vitamin and fluid intake (A and C) may also be beneficial
promote healing and reduce further risk. (D) is an intervention of last resort
because this will be very expensive for the client.
Which serum laboratory value should the nurse monitor carefully for a client who has a
nasogastric (NG) tube to suction for the past week?
A. White blood cell count
B. Albumin
, C. Calcium
D. Sodium
Give this one a try later!
Answer: D
Monitoring serum sodium levels (D) for hyponatremia is indicated during
prolonged NG suctioning because of loss of fluids. Changes in levels of (A, B,
or C) are not typically associated with prolonged NG suctioning.
A 20-year-old female client with a noticeable body odor has refused to shower for the
last 3 days. She states, "I have been told that it is harmful to bathe during my period."
Which action should the nurse take first?
A. Accept and document the client's wish to refrain from bathing.
B. Offer to give the client a bed bath, avoiding the perineal area.
C. Obtain written brochures about menstruation to give to the client.
D. Teach the importance of personal hygiene during menstruation with the client.
Give this one a try later!
Answer: D
Because a shower is most beneficial for the client in terms of hygiene, the
client should receive teaching first (D), respecting any personal beliefs such as
cultural or spiritual values. After client teaching, the client may still choose (A
or B). Brochures reinforce the teaching (C).
When assisting a client from the bed to a chair, which procedure is best for the nurse to
follow?
A. Place the chair parallel to the bed, with its back toward the head of the bed and assist
the client in moving to the chair.
B. With the nurse's feet spread apart and knees aligned with the client's knees, stand and
client who does not speak English?
A. Ask an interpreter to provide wound care instructions.
B. Speak directly to the client, with an interpreter translating.
C. Request the accompanying family member to translate.
D. Instruct a bilingual employee to read the instructions.
Answer: B
Wound care instructions should be given directly to the client by the nurse
with an interpreter (B) who is trained to provide accurate and objective
translation in the client's primary language, so that the client has the
opportunity to ask questions during the teaching process. The interpreter
usually does not have any health care experience, so the nurse must provide
client teaching (A). Family members should not be used to translate
instructions (C) because the client or family member may alter the instructions
during conversation or be uncomfortable with the topics discussed. The
, employee should be a trained interpreter (D) to ensure that the nurse's
instructions are understood accurately by the client.
A client has a nasogastric tube connected to low intermittent suction. When
administering medications through the nasogastric tube, which action should the nurse
do first?
A. Clamp the nasogastric tube.
B. Confirm placement of the tube.
C. Use a syringe to instill the medications.
D. Turn off the intermittent suction device.
Answer: D
The nurse should first turn off the suction (D) and then confirm placement of
the tube in the stomach (B) before instilling the medications (C). To prevent
immediate removal of the instilled medications and allow absorption, the tube
should be clamped for a period of time (A) before reconnecting the suction.
Urinary catheterization is prescribed for a postoperative female client who has been
unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the
tubing. Which action will the nurse take next?
A. Clamp the catheter and recheck it in 60 minutes.
B. Pull the catheter back 3 inches and redirect upward.
C. Leave the catheter in place and reattempt with another catheter.
D. Notify the health care provider of a possible obstruction.
, Answer: C
It is likely that the first catheter is in the vagina, rather than the bladder.
Leaving the first catheter in place will help locate the meatus when attempting
the second catheterization (C). The client should have at least 240 mL of urine
after 8 hours. (A) does not resolve the problem. (B) will not change the
location of the catheter unless it is completely removed, in which case a new
catheter must be used. There is no evidence of a urinary tract obstruction if
the catheter could be easily inserted (D).
A 65-year-old client who attends an adult daycare program and is wheelchair-mobile
has redness in the sacral area. Which instruction is most important for the nurse to
provide?
A. Take a vitamin supplement tablet once a day.
B. Change positions in the chair at least every hour.
C. Increase daily intake of water or other oral fluids.
D. Purchase a newer model wheelchair.
Give this one a try later!
Answer: B
The most important teaching is to change positions frequently (B) because
pressure is the most significant factor related to the development of pressure
ulcers. Increased vitamin and fluid intake (A and C) may also be beneficial
promote healing and reduce further risk. (D) is an intervention of last resort
because this will be very expensive for the client.
Which serum laboratory value should the nurse monitor carefully for a client who has a
nasogastric (NG) tube to suction for the past week?
A. White blood cell count
B. Albumin
, C. Calcium
D. Sodium
Give this one a try later!
Answer: D
Monitoring serum sodium levels (D) for hyponatremia is indicated during
prolonged NG suctioning because of loss of fluids. Changes in levels of (A, B,
or C) are not typically associated with prolonged NG suctioning.
A 20-year-old female client with a noticeable body odor has refused to shower for the
last 3 days. She states, "I have been told that it is harmful to bathe during my period."
Which action should the nurse take first?
A. Accept and document the client's wish to refrain from bathing.
B. Offer to give the client a bed bath, avoiding the perineal area.
C. Obtain written brochures about menstruation to give to the client.
D. Teach the importance of personal hygiene during menstruation with the client.
Give this one a try later!
Answer: D
Because a shower is most beneficial for the client in terms of hygiene, the
client should receive teaching first (D), respecting any personal beliefs such as
cultural or spiritual values. After client teaching, the client may still choose (A
or B). Brochures reinforce the teaching (C).
When assisting a client from the bed to a chair, which procedure is best for the nurse to
follow?
A. Place the chair parallel to the bed, with its back toward the head of the bed and assist
the client in moving to the chair.
B. With the nurse's feet spread apart and knees aligned with the client's knees, stand and
