A nurse in a provider's office is talking with an older adult client who tells the nurse that they fear they are "aging badly" and feel "so useless." Which of the following assessment questions is the nurse's priority?

"Did anything in particular make you feel this way?"

"Would you tell me more about the changes you see in your body?"

"Do you ever think about harming yourself?"

"How long have you had these feelings of uselessness?"

Answer and Explanation

The Correct Answer is C

A. "Did anything in particular make you feel this way?" Understanding the cause of the client’s feelings is important, but assessing for immediate safety takes priority.
B. "Would you tell me more about the changes you see in your body?" Exploring the client’s perception of aging is useful, but it does not address potential risk for self-harm.
C. "Do you ever think about harming yourself?" This is the priority assessment question because feelings of worthlessness can indicate depression, which increases the risk of suicide in older adults. Assessing for self-harm ensures immediate safety.
D. "How long have you had these feelings of uselessness?" Identifying the duration of these feelings is relevant, but it is secondary to determining whether the client is at risk for self-harm.

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Correct Answer is D

Explanation

A. Lubricating the catheter with water-soluble gel is important but is done after preparing the sterile field.
B. Attaching a prefilled syringe to the catheter inflation hub is performed after insertion to secure the catheter, not before.
C. Cleansing the client’s meatus with antiseptic solution is essential for infection prevention but is done after the sterile field is set up.
D. Positioning the sterile drape while leaving the perineum exposed is the first step because it maintains a sterile field and provides a clean working area for catheter insertion. This prevents contamination and reduces the risk of infection.

A. Reinsert the protruding intestinal tissue. B. Place the client in Trendelenburg position. C. Cover the wound with a saline-soaked dressing. over D. Monitor vital signs every 30 min.

Correct Answer is C

Explanation

A. Reinserting the protruding intestinal tissue is inappropriate and can cause further injury or infection. The nurse should keep the tissue moist and protected until surgical intervention.
B. Placing the client in Trendelenburg position is incorrect because it does not reduce tension on the wound. Instead, the client should be placed in a low Fowler's position with knees slightly flexed to reduce strain.
C. Covering the wound with a sterile saline-soaked dressing is the priority action to keep the tissue moist and prevent further contamination or damage until the provider can intervene.
D. Monitoring vital signs every 30 minutes is important but not the priority action. The nurse should immediately cover the wound first, then monitor for signs of shock or infection.

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A nurse in a provider's office is talking with an older adult client who tells the nurse that they fear they are "aging badly" and feel "so useless." Which of the following assessment questions is the nurse's priority?

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse is caring for a client who is postoperative following abdominal surgery. The client reports feeling like "something opened up." The nurse peels back the dressing to find separation of the incision with protrusion of intestinal tissue. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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