Question

A nurse instructs a female client about collecting a midstream urine sample. Which of the following client statements indicates an understanding of the procedure?

Answer 1

Correct Answers:

I'll use the cleansing wipe from front to back.

Rationale :

Wiping from front to back prevents contamination of the urinary tract with bacteria from the perineal area, reducing the risk of urinary tract infections (UTIs). Proper perineal hygiene is essential in obtaining an uncontaminated midstream urine sample, ensuring accurate diagnostic results.

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Answer 2

Correct Answers:

Remove all metal necklaces.

Rationale :

Metal objects can interfere with the imaging process during a chest X-ray, potentially obscuring structures and leading to inaccurate results. Removing all metallic accessories ensures a clear and precise radiographic image for proper diagnostic evaluation.

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Answer 3

Correct Answers:

Determine the location of the pain

Rationale :

Assessing the location, intensity, and characteristics of pain before administering medication ensures appropriate and targeted pain management. Identifying the source of pain can guide non-pharmacologic interventions, improving overall pain control.

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Answer 4

Correct Answers:

Apply 4 to 5 ml of liquid soap to the hands

Rationale :

Using an adequate amount of soap ensures effective removal of dirt, bacteria, and pathogens, reducing the risk of infections. Proper hand hygiene techniques prevent the spread of hospital-acquired infections and promote patient safety.

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Answer 5

Correct Answers:

Necrotic subcutaneous tissue

Rationale :

A Stage 3 pressure ulcer is characterized by full-thickness skin loss with damage extending into the subcutaneous tissue but without exposure of muscle, bone, or tendons. Necrotic tissue may be present, requiring debridement for optimal wound healing and infection prevention.

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Answer 6

Correct Answers:

Provide the client with a diet high in protein

Rationale :

Protein plays a vital role in skin integrity by promoting tissue repair and regeneration, reducing the risk of skin breakdown. A high-protein diet helps prevent pressure ulcers by supporting collagen formation and immune function.

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Answer 7

Correct Answers:

Explain to the client what is about to happen

Rationale :

Providing clear explanations reduces anxiety and prepares the client for what to expect during the physical examination. Older adults may experience cognitive or sensory deficits, making clear communication essential for cooperation and comfort.

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Answer 8

Correct Answers:

I will no longer have a glass of wine before bedtime

Rationale :

Alcohol consumption before bed can disrupt sleep patterns, leading to poor-quality sleep and increased nighttime awakenings. Avoiding alcohol as a sleep aid promotes healthier sleep hygiene and improves overall restfulness.

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Answer 9

Correct Answers:

Avoid movements that twist the spine

Rationale :

Twisting motions can strain the back and increase the risk of injury for both the client and the caregiver during transfers. Using proper body mechanics, such as maintaining a neutral spine, reduces musculoskeletal strain and enhances safety.

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Answer 10

Correct Answers:

Neutropenic

Rationale :

Clients who have undergone allogeneic stem-cell transplants are immunocompromised and require neutropenic precautions to minimize infection risk. Protective isolation involves strict hand hygiene, visitor restrictions, and avoidance of fresh flowers or raw foods.

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NURS 102 Fundamentals Retake

No.

1 : A nurse instructs a female client about collecting a midstream urine sample. Which of the following client statements indicates an understanding of the procedure?

2 : As part of an annual physical examination, a nurse is preparing a client to undergo a chest x-ray. Which of the following instructions should the nurse give the client prior to the procedure?

3 : A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first?

4 : A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take?

5 : A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer?

6 : A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

7 : A nurse is preparing an older adult client for a physical examination the provider is about to perform. Which of the following actions should the nurse take?

8 : A nurse is teaching a client who reports insomnia about promoting rest and sleep. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

9 : A nurse is preparing to assist a client who can partially bear weight and is cooperative with transfer from the bed to a chair.

Which of the following actions should the nurse take to maintain safety during the transfer?

10 : A nurse is caring for a client who has had an allogeneic hematopoietic stem-cell transplant. Which of the following infection-control precautions should the nurse use while caring for this client?

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NURS 102 Fundamentals Retake

No.

1 : A nurse instructs a female client about collecting a midstream urine sample. Which of the following client statements indicates an understanding of the procedure?

2 : As part of an annual physical examination, a nurse is preparing a client to undergo a chest x-ray. Which of the following instructions should the nurse give the client prior to the procedure?

3 : A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first?

4 : A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take?

5 : A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer?

6 : A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

7 : A nurse is preparing an older adult client for a physical examination the provider is about to perform. Which of the following actions should the nurse take?

8 : A nurse is teaching a client who reports insomnia about promoting rest and sleep. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

9 : A nurse is preparing to assist a client who can partially bear weight and is cooperative with transfer from the bed to a chair.Which of the following actions should the nurse take to maintain safety during the transfer?

10 : A nurse is caring for a client who has had an allogeneic hematopoietic stem-cell transplant. Which of the following infection-control precautions should the nurse use while caring for this client?

9 : A nurse is preparing to assist a client who can partially bear weight and is cooperative with transfer from the bed to a chair.

Which of the following actions should the nurse take to maintain safety during the transfer?