A nurse is caring for a client who is 1 day postoperative following abdominal surgery. Which of the following client statements indicates a need for further instruction?

"I will get up and walk with the physical therapy aide."

"I will do leg exercises every hour while I am awake."

"I will take off my antiembolic stockings before I go to bed."

"I will use a footstool while I sit in a chair."

Answer and Explanation

The Correct Answer is C

A.   Getting up and walking with the physical therapy aide promotes early mobility and is a positive statement.
B.   Doing leg exercises every hour while awake helps prevent complications such as deep vein thrombosis (DVT).
C.   Leaving antiembolic stockings on during sleep helps prevent DVT, so the client's statement is incorrect.
D.   Using a footstool while sitting in a chair promotes proper positioning and comfort.

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Correct Answer is B

Explanation

A. The frequency of previous vital sign measurements may be important but is not the most critical information to communicate during a transfer.
B. The effectiveness of the last dose of pain medication is crucial information for the receiving facility to manage the client's pain appropriately.
C. The number of family members who have visited is important for emotional support but may not be the priority for the receiving facility.
D. The time of the client's last bath is relevant but may not be as critical as information related to pain management during the hand-off report.

A. Show the client how to use an artificial larynx. B. Arrange a support session for the client. C. Demonstrate the use of esophageal speech. D. Determine the client's reading ability.

Correct Answer is D

Explanation

A. Showing the client how to use an artificial larynx is an important aspect of post-laryngectomy care, but determining the client's reading ability takes precedence as it will significantly impact communication options.
B. Arranging a support session is important for emotional support, but assessing the client's reading ability is more immediate in addressing communication needs.
C. Demonstrating the use of esophageal speech is relevant, but understanding the client's reading ability is a priority before exploring communication alternatives.

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A nurse is caring for a client who is 1 day postoperative following abdominal surgery. Which of the following client statements indicates a need for further instruction?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an acute care facility is preparing to transfer a client to a long-term care facility. Which of the following information should the nurse include in the hand-off report?

Correct Answer is B

Explanation

A nurse is providing care for a client who is scheduled for a total laryngectomy. Which of the following is the nurse's priority intervention?

Correct Answer is D

Explanation

A nurse is delegating obtaining the collection of a client's oral temperature to an assistive personnel (AP). The nurse notes in the documentation that the AP obtained the client's axillary temperature. Which of the following rights of delegation should have prevented this situation from occurring?

A provider prescribes cold application for a client who reports ankle joint stiffness. Which of the following assessment findings should the nurse identify as a contraindication to the application of cold?

A nurse is preparing to insert an indwelling urinary catheter. Which of the following instructions should the nurse give the client to help ease the passage of the catheter through the urinary meatus?

A nurse is caring for a client who is unconscious. Which of the following actions is appropriate for the nurse to take when providing the client's oral care?

A nurse is caring for a client who has a stage II pressure ulcer. Which of the following products should the nurse use to treat the ulcer?

A nurse is teaching an assistive personnel (AP) how to obtain a capillary finger stick blood sample. Which of the following actions by the AP requires the nurse to intervene?

To plan culturally competent care, a nurse should consider that:

A nurse is caring for a client who has a new prescription for a medication that she thinks may be harmful to the client. After seeking clarification from the provider, the nurse still feels that it is unsafe. Which of the following actions should the nurse take?