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1. A healthcare provider is caring for a client with a pressure ulcer and needs to review the client's medical history. Which of the following findings is expected?
- A. A Braden scale score of 20
- B. An albumin level of 3 g/dL
- C. A hemoglobin level of 13 g/dL
- D. A Norton scale score of 18
Correct answer: B
Rationale: A serum albumin level of 3 g/dL is indicative of poor nutrition, a common factor in the development of pressure ulcers. The Braden scale assesses the risk of developing pressure ulcers but does not reflect the client's medical history. Hemoglobin level is more related to oxygen-carrying capacity rather than pressure ulcer development. The Norton scale evaluates risk for developing pressure ulcers but is not typically part of a client's medical history.
2. A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP?
- A. The roommate is up independently
- B. The client ambulates with his slippers on over his antiembolic stockings
- C. The client uses a front-wheeled walker when ambulating
- D. The client had pain meds 30 minutes ago
Correct answer: C
Rationale: The correct answer is C. After knee arthroplasty, it is essential for the client to use a front-wheeled walker when ambulating to ensure stability and prevent falls. Sharing this information with the assistive personnel (AP) is crucial for the client's safety and proper rehabilitation. Choices A, B, and D are incorrect because the roommate's independence, the client's footwear over stockings, and the timing of pain medication administration are not directly related to the safe ambulation of a client post-knee arthroplasty.
3. Which type of infectious diseases are required to be reported to the health department?
- A. Staphylococcus aureus infections, including MRSA
- B. Severe cases of flu-like symptoms
- C. Common colds and non-severe respiratory infections
- D. Only contagious diseases like meningitis
Correct answer: A
Rationale: The correct answer is A: Staphylococcus aureus infections, including MRSA. Severe infections like MRSA are required to be reported to the health department as they pose a significant public health risk. Choices B, C, and D are incorrect because severe flu-like symptoms, common colds, and non-severe respiratory infections, and only contagious diseases like meningitis do not fall under the category of infectious diseases that must be reported to the health department.
4. A client is experiencing difficulty voiding following the removal of an indwelling catheter. What action should the nurse take to assist the client?
- A. Assess for bladder distention after 4 hours
- B. Pour warm water over the perineum
- C. Restrict the client's oral fluid intake
- D. Restrict movement for at least 12 hours
Correct answer: B
Rationale: The correct action for the nurse to assist the client who is experiencing difficulty voiding after the removal of an indwelling catheter is to pour warm water over the perineum. This technique can help stimulate urination by promoting relaxation of the perineal muscles and improving blood flow to the area. Assessing for bladder distention after 4 hours (Choice A) is important but not the immediate intervention needed to assist the client in voiding. Restricting the client's oral fluid intake (Choice C) can exacerbate the issue by reducing urine production. Restricting movement for at least 12 hours (Choice D) is unnecessary and may lead to discomfort and other complications.
5. A client undergoing chemotherapy for cancer is being taught about potential adverse effects of the treatment. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will avoid drinking water before meals
- B. I might experience hair loss during treatment
- C. I might experience an increase in appetite
- D. I should expect my appetite to increase
Correct answer: B
Rationale: The correct answer is B because hair loss is a common adverse effect of chemotherapy. Options A, C, and D are incorrect. Avoiding drinking water before meals, experiencing an increase in appetite, or expecting appetite to increase are not related to the potential adverse effects of chemotherapy.
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