Question

A nurse is caring for a client.

Answer 1

Correct Answers:

Use of interpreter.
Integrate religious beliefs with plan of care.
Express interest in client's culture.

Rationale :

✅ Use of interpreter

💎 Using interpreter services demonstrates cultural competence because the client recently immigrated from Vietnam and speaks a different language than the nurse.

💎 A trained interpreter helps ensure accurate communication about symptoms, medications, safety concerns, treatment options, and emotional needs.

💎 This protects the client’s right to understand care and participate in decisions.

💎 It also prevents errors that can occur when language barriers interfere with assessment or teaching.

💎 Using interpreter services shows respect for the client’s language needs and supports safe, patient-centered care.

✅ Integrate religious beliefs with plan of care

🔷 Integrating the client’s religious practices into the care plan shows respect for the client’s values, identity, and coping methods.

🔷 Cultural competence includes asking about spiritual and religious practices instead of assuming what matters to the client.

🔷 Religious practices may support comfort, hope, emotional stability, and connection during depression treatment.

🔷 Including these practices can improve trust and treatment adherence.

🔷 This action helps create a care plan that is meaningful and individualized.

✅ Express interest in client’s culture

🟢 The nurse discussed the client’s culture, religious practices, heritage, and feelings of loss of connection.

🟢 This demonstrates cultural competence because the nurse is showing curiosity, respect, and willingness to understand the client’s lived experience.

🟢 Recent immigration can involve grief, isolation, language barriers, and loss of cultural connection, which may worsen depression.

🟢 Asking about culture helps the nurse avoid assumptions and provide more personalized care.

🟢 This supports therapeutic communication and builds trust.

❌ Implementation of suicide precautions

❌ Suicide precautions are clinically appropriate because the client did not respond when asked about self-harm.

❌ However, this action reflects safety and risk management, not cultural competence specifically.

❌ Client teaching about medications

❌ Medication teaching is important nursing care and supports informed treatment.

❌ However, by itself, teaching about medications does not specifically demonstrate cultural competence unless it is adapted to the client’s language, beliefs, and preferences.

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Answer 2

Correct Answers

Blank 1 Correct Option: safety
Blank 2 Correct Option: notify Adult Protective Services

Rationale :

✅ Safety

💎 Safety is the priority because the client has multiple findings that suggest immediate risk for harm.

💎 The client has an unsteady gait and reports dizziness with standing, which increases the risk for another fall.

💎 Multiple abrasions and bruises in various stages of healing may indicate repeated injury, poor supervision, possible neglect, or possible mistreatment.

💎 The client also has poor hygiene, body odor, lice, unclean nails, and decreased skin turgor, which suggest unmet basic care needs.

💎 The nurse should first protect the client from further injury by using fall precautions, close observation, assistance with ambulation, and environmental safety measures.

✅ Notify Adult Protective Services

🔷 The findings raise concern for elder neglect or possible abuse, so Adult Protective Services should be notified.

🔷 Bruising in different stages of healing, multiple abrasions, poor hygiene, strong urine odor, lice, and delayed care needs are concerning signs.

🔷 The client depended on relatives after a fall, but the family reports being busy, suggesting possible inability or failure to provide adequate care.

🔷 Nurses are mandated reporters and must report suspected abuse or neglect according to facility policy and state law.

🔷 The nurse does not need proof of abuse before reporting; reasonable suspicion is enough to initiate protective follow-up.

❌ Risk of falls

❌ Risk of falls is important because the client has dizziness, unsteady gait, and a history of falling.

❌ However, the broader priority is safety, which includes fall prevention plus protection from possible neglect or injury.

❌ Hygiene

❌ Hygiene is a concern because the client has unclean hair, lice, long dirty nails, urine odor, and poor personal care.

❌ However, hygiene is not the highest priority compared with protecting the client from harm and addressing possible elder neglect.

❌ Trim nails

❌ Trimming nails may improve hygiene and reduce scratching or skin injury.

❌ It is not the priority follow-up action when abuse or neglect is suspected.

❌ Determine range of motion

❌ Range of motion assessment may be useful later to evaluate mobility and function.

❌ It does not address the immediate safety concern or the suspected neglect/abuse indicators.

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Answer 3

Correct Answers:

Determine how the client views the concept of a family.

Rationale :

💎 During a family assessment, the first priority is to identify who the client considers family because family structure and support systems differ among individuals and cultures.

💎 Family is not always defined by biological relationships; clients may identify spouses, friends, neighbors, caregivers, or community members as family.

💎 Since the client recently developed paraplegia following a stroke, understanding who the client relies on helps the nurse identify available support and plan care appropriately.

💎 Establishing the client’s definition of family creates the foundation for assessing roles, coping mechanisms, support systems, and care needs.

💎 Family-centered nursing begins with respecting the client’s personal understanding of family rather than making assumptions.

💎 Once the family structure is identified, additional assessments can explore culture, support systems, and adaptation.

❌ Identify how culture influences family functioning

❌ Culture affects beliefs, caregiving roles, and family interactions.

❌ However, the nurse must first identify who the client considers family before evaluating cultural influences.

❌ Determine if the client has an external support system

❌ Support systems are important after a disabling condition such as paraplegia.

❌ This assessment occurs after understanding family structure.

❌ Identify how the family deals with unexpected health changes

❌ Coping and adaptation are important assessment areas.

❌ These are explored after establishing who makes up the family unit.

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Answer 4

Correct Answers:

30° lateral

Rationale :

💎 The 30° lateral position is recommended to reduce pressure on bony prominences in immobile clients and decrease the risk of pressure injuries.

💎 This position shifts pressure away from high-risk areas such as the sacrum, greater trochanter, and hips while maintaining alignment and comfort.

💎 Full side-lying positions increase direct pressure over the trochanter, increasing tissue ischemia risk.

💎 Using the 30° lateral tilt distributes weight more evenly and promotes circulation to vulnerable tissues.

💎 Pressure injury prevention also includes frequent repositioning, skin assessment, moisture control, and adequate nutrition.

💎 This position is widely recommended for clients with limited mobility.

❌ Lateral semi-prone recumbent

❌ This position is not routinely used specifically for pressure injury prevention.

❌ It may still place increased pressure on certain body areas.

❌ Supine

❌ Supine positioning places continuous pressure on the occiput, scapulae, sacrum, elbows, and heels.

❌ Prolonged supine positioning increases pressure injury risk.

❌ 45° supported Fowler's

❌ Fowler’s position increases shearing forces, especially over the sacrum.

❌ Elevated positioning should be minimized unless clinically necessary.

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Answer 5

Correct Answers:

A client who has dysphagia and has a scheduled feeding

Rationale :

💎 This client should be seen first because dysphagia creates an immediate airway and aspiration risk, making this the highest priority using ABCs (Airway, Breathing, Circulation).

💎 Clients with swallowing difficulty are at increased risk for aspiration pneumonia, airway obstruction, choking, and respiratory compromise during feeding.

💎 Before feeding, the nurse should assess swallowing ability, position the client upright, confirm dietary consistency orders, and monitor for coughing or difficulty swallowing.

💎 Feeding delays may also affect nutrition and medication administration.

💎 This situation involves a potential threat to life and takes priority over routine care activities.

💎 Priority nursing care focuses first on conditions that can compromise oxygenation and airway protection.

❌ A client who needs their daily weight taken with a bed scale

❌ Daily weights are important for monitoring fluid status and treatment response.

❌ However, this is routine care and does not represent an immediate physiologic risk.

❌ A client who has a leg ulcer and needs their dressing changed

❌ Dressing changes are necessary for wound healing and infection prevention.

❌ Unless signs of severe infection or bleeding are present, this is not the highest priority.

❌ A client who has an indwelling urinary catheter bag that needs to be emptied

❌ Emptying a catheter bag is important to maintain drainage and monitor output.

❌ This task is lower priority compared with airway safety concerns.

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Answer 6

Correct Answers:

Encourage the family member to contact the client directly for information.

Rationale :

💎 Client information is protected under confidentiality and privacy standards.

💎 Unless the nurse has verified authorization from the client, information should not be disclosed over the telephone.

💎 Encouraging the family member to contact the client directly protects confidentiality and allows the client to decide what information to share.

💎 Nurses should avoid assuming that relatives automatically have permission to receive updates.

💎 Protecting privacy is an ethical and legal nursing responsibility.

💎 Client consent determines who may receive healthcare information.

❌ Request additional information about the caller's relationship to the client

❌ Knowing the relationship alone does not authorize disclosure.

❌ Even family members may not have permission to receive information.

❌ Provide a general update about the client's condition over the telephone

❌ Giving updates without authorization breaches confidentiality.

❌ Information should not be shared unless proper consent exists.

❌ Refer the family member to the client's provider for the update

❌ Referral does not solve the confidentiality issue.

❌ Authorization is still required before any healthcare team member shares information.

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Answer 7

Correct Answers:

Ask a second nurse to witness the discarding of unused opioid medication.

Rationale :

💎 Opioids are controlled substances, so any unused or wasted portion must be discarded according to facility policy with a second licensed nurse witness.

💎 A second nurse verifies the amount wasted, observes disposal, and co-signs the controlled substance record.

💎 This process prevents diversion, protects client safety, and maintains legal accountability.

💎 Opioid handling requires accurate documentation of the dose removed, dose administered, dose wasted, and remaining count when required.

💎 Wasting should occur in an approved medication disposal system, not in an unsafe or unverified manner.

❌ Dispose of the wasted portion in the sharps box.

❌ A sharps box is for needles and sharp items, not routine medication wasting.

❌ Controlled medication waste must follow facility policy and usually requires witnessed disposal.

❌ Count the total amount remaining after removing the needed amount.

❌ Controlled substance counts are important, but the priority action related to unused opioid medication is witnessed wasting.

❌ Counting alone does not safely account for discarded medication.

❌ Report opioid count discrepancies to the provider.

❌ Count discrepancies should be reported according to facility policy, usually to the charge nurse, pharmacy, or supervisor.

❌ The provider is not usually the first person responsible for controlled-substance count reconciliation.

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Answer 8

Correct Answers:

"I will store oxygen tanks in an upright position."

Rationale :

💎 Compressed oxygen cylinders should be stored upright and secured to prevent falling, rolling, or damage to the valve.

💎 If a tank falls and the valve breaks, the cylinder can become a dangerous projectile.

💎 Oxygen supports combustion, so safe storage is essential in the home environment.

💎 The client should keep tanks away from flames, smoking materials, grease, oil, and heat sources.

💎 Oxygen equipment should be checked regularly, and the prescribed flow rate should be followed exactly.

❌ “I will regulate the oxygen flow rate as needed.”

❌ The client should not change the flow rate unless instructed by the provider.

❌ Too much or too little oxygen can cause harm depending on the client’s condition.

❌ “I should check the oxygen equipment once per week.”

❌ Oxygen equipment should be checked daily, not only weekly.

❌ The client should check tubing, flow, tank supply, humidifier if used, and safety setup.

❌ “I should place the oxygen equipment 4 feet from a heat source.”

❌ Oxygen should be kept at least 5 feet from heat sources, flames, or electrical hazards.

❌ Four feet is not enough distance for safe oxygen use.

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Answer 9

Correct Answers:

"I'll compare the sensations I feel when I tense my muscles to what I feel when I relax them."

Rationale :

💎 Progressive muscle relaxation involves systematically tensing and relaxing muscle groups.

💎 The client learns to recognize the difference between muscle tension and relaxation.

💎 This technique helps reduce stress, anxiety, muscle tightness, and physiologic arousal.

💎 The client usually starts with one muscle group and moves through the body in a structured pattern.

💎 Comparing the feelings of tension and relaxation shows correct understanding of the technique.

❌ “I should breathe normally while performing this relaxation technique.”

❌ Breathing calmly is helpful, but it is not the defining feature of progressive muscle relaxation.

❌ The key action is alternating muscle tension and relaxation.

❌ “I should imagine myself in a peaceful, garden-like setting.”

❌ This describes guided imagery, not progressive muscle relaxation.

❌ Guided imagery uses mental visualization to reduce stress.

❌ “I’ll use a series of stretches when I practice this technique.”

❌ Stretching is not the same as progressive muscle relaxation.

❌ Progressive relaxation focuses on tightening and releasing muscles, not stretching.

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Answer 10

Correct Answers:

Ask the client whether they have created advance directives.

Rationale :

💎 Under the Patient Self-Determination Act (PSDA), healthcare facilities are required to ask clients upon admission whether they have advance directives and document the response in the medical record.

💎 Advance directives are legal documents that communicate a client’s wishes regarding future healthcare decisions if they become unable to speak for themselves. Examples include a living will and durable power of attorney for healthcare.

💎 The nurse’s responsibility is to determine whether advance directives exist, document their presence, provide information if requested, and ensure the client’s rights are respected.

💎 The PSDA protects the client’s right to participate in healthcare decisions and promotes autonomy and informed decision-making.

💎 Nurses should support the client’s choices but should not pressure the client to create or change advance directives.

💎 Asking about advance directives early in admission ensures healthcare decisions align with the client’s wishes during future care.

❌ Assist the client in making decisions about the need for life support

❌ The nurse provides education and clarifies information but does not make or direct life-support decisions for the client.

❌ Decisions about treatment preferences belong to the client.

❌ Notify the provider of the client's durable power of attorney for health care

❌ If a durable power of attorney exists, the information may become relevant later.

❌ The nurse’s first responsibility under PSDA is to determine whether advance directives exist.

❌ Clarify the legal competency of the client

❌ Legal competency is determined through legal processes and authorized providers, not by the nurse.

❌ Nurses assess orientation and understanding but do not establish legal competency.

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QLexNursing

1 :
A nurse is caring for a client.

Answer Options

2 :
A nurse is caring for an older adult client being admitted into a long-term care facility.

Correct Answers

3 :
A nurse is performing a family assessment for a client who has recently developed paraplegia following a stroke. Which of the following actions should the nurse take first?

4 :
A nurse is caring for a client who is at risk for pressure injury formation due to immobility. The nurse should place the client in which of the following positions to reduce pressure on the client's bony prominences?

5 :
A nurse is receiving a change-of-shift report for a group of clients. Which of the following clients should the nurse plan to see first?

6 :
A nurse receives a telephone call from a client's family member, who asks the nurse for an update on the client's condition. Which of the following actions should the nurse take to maintain the client's confidentiality?

7 :
A nurse is preparing to administer an opioid medication to a client who is experiencing pain. Which of the following actions should the nurse take?

8 :
A nurse is providing discharge teaching to a client who has a new prescription for home oxygen therapy using a compressed oxygen system. Which of the following statements by the client indicates an understanding of the teaching?

9 :
A nurse is teaching a client to manage stress by using progressive relaxation techniques. Which of the following statements by the client indicates an understanding of the teaching?

10 :
A nurse is admitting a client who is to undergo a surgical procedure. Under the Patient Self-Determination Act (PSDA), which of the following actions is the nurse's responsibility regarding the client's advance directives?

QLexNursing

1 : A nurse is caring for a client.

Answer Options

2 : A nurse is caring for an older adult client being admitted into a long-term care facility.

Correct Answers

3 : A nurse is performing a family assessment for a client who has recently developed paraplegia following a stroke. Which of the following actions should the nurse take first?

4 : A nurse is caring for a client who is at risk for pressure injury formation due to immobility. The nurse should place the client in which of the following positions to reduce pressure on the client's bony prominences?

5 : A nurse is receiving a change-of-shift report for a group of clients. Which of the following clients should the nurse plan to see first?

6 : A nurse receives a telephone call from a client's family member, who asks the nurse for an update on the client's condition. Which of the following actions should the nurse take to maintain the client's confidentiality?

7 : A nurse is preparing to administer an opioid medication to a client who is experiencing pain. Which of the following actions should the nurse take?

8 : A nurse is providing discharge teaching to a client who has a new prescription for home oxygen therapy using a compressed oxygen system. Which of the following statements by the client indicates an understanding of the teaching?

9 : A nurse is teaching a client to manage stress by using progressive relaxation techniques. Which of the following statements by the client indicates an understanding of the teaching?

10 : A nurse is admitting a client who is to undergo a surgical procedure. Under the Patient Self-Determination Act (PSDA), which of the following actions is the nurse's responsibility regarding the client's advance directives?

1 :
A nurse is caring for a client.

2 :
A nurse is caring for an older adult client being admitted into a long-term care facility.

3 :
A nurse is performing a family assessment for a client who has recently developed paraplegia following a stroke. Which of the following actions should the nurse take first?

4 :
A nurse is caring for a client who is at risk for pressure injury formation due to immobility. The nurse should place the client in which of the following positions to reduce pressure on the client's bony prominences?

5 :
A nurse is receiving a change-of-shift report for a group of clients. Which of the following clients should the nurse plan to see first?

6 :
A nurse receives a telephone call from a client's family member, who asks the nurse for an update on the client's condition. Which of the following actions should the nurse take to maintain the client's confidentiality?

7 :
A nurse is preparing to administer an opioid medication to a client who is experiencing pain. Which of the following actions should the nurse take?

8 :
A nurse is providing discharge teaching to a client who has a new prescription for home oxygen therapy using a compressed oxygen system. Which of the following statements by the client indicates an understanding of the teaching?

9 :
A nurse is teaching a client to manage stress by using progressive relaxation techniques. Which of the following statements by the client indicates an understanding of the teaching?

10 :
A nurse is admitting a client who is to undergo a surgical procedure. Under the Patient Self-Determination Act (PSDA), which of the following actions is the nurse's responsibility regarding the client's advance directives?