Question

A charge nurse is observing a staff nurse performing wound irrigation for a client who has a pressure injury. Which of the following actions by the staff nurse indicates an understanding of the procedure?

Answer 1

Correct Answers:

Uses a syringe with a catheter for wound irrigation

Rationale :

🔵Using a syringe with a catheter provides controlled pressure and direction during wound irrigation, allowing the solution to cleanse the wound bed thoroughly without damaging tissue.

🔵This technique supports effective removal of debris and exudate, reduces infection risk, and aligns with evidence-based wound care practices.

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Answer 2

Correct Answers:

Allow the client to slide down their outstretched leg

Rationale :

✍When a client begins to fall, the nurse should protect them from injury by allowing them to slide down the nurse’s outstretched leg to the floor.

✍ This technique controls the descent, minimizes impact, and prevents both client and nurse from injury during a fall.

✍It follows safe fall-assist protocol.

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Answer 3

Correct Answers:

Insert an indwelling urinary catheter and connect it to gravity drainage.

Rationale :

✍Postoperative clients may experience urinary retention due to the effects of anesthesia, stress, or immobility.

✍The sound of running water activates the parasympathetic nervous system, which stimulates the micturition reflex and promotes relaxation of the urinary sphincter, making voiding easier.

✍This non-invasive intervention is a first-line nursing strategy that supports restoration of normal elimination patterns.

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Answer 4

Correct Answers:

Clear the nearby area of furniture.

Rationale :

💎During a seizure, the nurse’s immediate priority is to ensure the client's safety by preventing injury.

💎Clearing furniture and objects from the surrounding area helps avoid trauma to the head or limbs during involuntary movements.

💎This action aligns with seizure precautions and is a critical nursing intervention for clients with known or suspected seizure activity.

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Answer 5

Correct Answers:

Eyelashes that curl slightly outward.

Rationale :

✍Outward-curling eyelashes are a normal anatomical feature that provides protective function by diverting debris and particles away from the corneal surface.

✍During a head-to-toe assessment, this finding indicates normal eyelid structure and hair growth pattern, supporting ocular health and reducing irritation or injury risk.

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Answer 6

Correct Answers:

Restlessness

Rationale :

♦In a postoperative client, restlessness is often an early indicator of complications, such as hypoxia, internal bleeding, or fluid volume deficit.

♦It reflects neurological changes due to inadequate oxygen delivery or perfusion.

♦Recognizing this subtle change in behavior allows the nurse to intervene promptly before vital signs become unstable, enhancing early detection of clinical deterioration.

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Answer 7

Correct Answers:

I will walk three times per week.

Rationale :

🟣Weight-bearing activities, like walking, are effective in stimulating bone formation and maintaining bone mineral density, which helps prevent osteoporosis.

🟣Regular ambulation also enhances joint flexibility and balance, reducing the risk of falls.

🟣This commitment demonstrates understanding of a long-term lifestyle strategy for preserving musculoskeletal health.

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Answer 8

Correct Answers:

"We can discuss several scheduling options for monitoring your blood glucose."

Rationale :

▶Engaging the client in a collaborative discussion fosters shared decision-making, improves treatment adherence, and supports individualized care.

▶Offering scheduling options acknowledges the client’s preferences while reinforcing the importance of blood glucose monitoring for diabetes management.

▶This approach is consistent with therapeutic communication and patient autonomy.

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Answer 9

Correct Answers:

When lifting the box, keep it close to the body

Rationale :

✍Maintaining the load close to the body’s center of gravity reduces strain on the lower back and utilizes core stability and leg strength.

✍This technique is a foundational principle of safe body mechanics, helping to prevent musculoskeletal injury and support ergonomic work practices in healthcare settings.

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Answer 10

Correct Answers:

Measure the length of the client's leg from the heel to the gluteal fold.

Rationale :

📌Correct measurement for knee-length antiembolic stockings ensures they fit properly and apply graduated compression to enhance venous return and reduce the risk of deep vein thrombosis (DVT).

📌 Measuring from the heel to the popliteal fold is essential to achieve a snug fit that is neither too loose nor constrictive, maintaining both effectiveness and comfort.

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RN Fundamentals~2023 Exam 5

No.

1 : A charge nurse is observing a staff nurse performing wound irrigation for a client who has a pressure injury. Which of the following actions by the staff nurse indicates an understanding of the procedure?

2 : A nurse is ambulating a client who is unsteady. The client begins to fall. Which of the following actions should the nurse take?

3 : A nurse is caring for a client who is 6 hours postoperative following abdominal surgery and is having difficulty voiding. Which of the following actions should the nurse take?

4 : A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take?

5 : A nurse is performing an eye assessment for a newly admitted client. Which of the following findings should the nurse expect?

6 : A nurse is caring for a postoperative client. Which of the following findings indicate the client may be actively bleeding?

7 : A nurse is teaching an older adult client about reducing the risk for osteoporosis. Which of the following statements by the client indicates an understanding of the teaching?

8 : A nurse is caring for a client who has a new diagnosis of insulin- dependent diabetes mellitus. The client states, "l am concerned about being able to monitor my blood glucose regularly due to my busy schedule." Which of the following responses should the nurse make?

9 : A nurse is preparing to lift a box of personal items off the floor in a client's room. Which of the following actions should the nurse take to help prevent injury when lifting the box?

10 : A nurse is planning care for a client who has a prescription for knee-length antiembolic stockings. Which of the following actions should the nurse take?

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