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 :

📌For a midstream clean-catch urine specimen, cleansing the perineal area from front to back is critical in preventing contamination with fecal bacteria, particularly E. coli, which can lead to inaccurate results or false positives for urinary tract infections.

📌This method helps maintain sterility of the sample, ensuring that lab analysis reflects only the microbial flora of the urinary tract.

📌This is a standard aseptic practice in urine collection.

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Answer 2

Correct Answers:

Remove all metal necklaces.

Rationale :

♦In preparation for a chest X-ray, the client must remove all metallic items, especially jewelry, to avoid artifact formation that can obscure key anatomical structures, such as the lungs, heart, and mediastinum.

♦This step prevents misinterpretation of the radiographic image, reduces the need for repeat imaging, and ensures diagnostic accuracy.

♦This is a critical part of pre-procedure preparation.

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Answer 3

Correct Answers:

Determine the location of the pain.

Rationale :

✍ According to the nursing process, the first and foundational step is assessment.

✍Identifying the location, severity, and characteristics of pain allows the nurse to ensure that the correct medication, route, and timing are appropriate and safe.

✍Assessing before intervening avoids mismanagement and promotes targeted relief, especially when multiple pain sources may exist.

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Answer 4

Correct Answers:

Apply 4 to 5 ml of liquid soap to the hands.

Rationale :

💥Hand hygiene requires adequate soap volume to create lather that fully covers palms, backs of hands, fingers, and fingernails.

💥Using 4–5 mL of soap ensures mechanical removal of transient microorganisms, which is crucial in preventing healthcare-associated infections (HAIs).

💥The CDC and WHO recommend this standard to reduce cross-contamination between patients.

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Answer 5

Correct Answers:

Necrotic subcutaneous tissue

Rationale :

A stage 3 pressure injury involves full-thickness skin loss, extending into the subcutaneous tissue but not exposing bone or muscle.
The presence of necrotic tissue (slough or eschar) is typical in this stage and requires debridement and advanced wound care.
Recognizing pressure ulcer stages allows for timely intervention, preventing progression to stage 4 or infection.

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Answer 6

Correct Answers:

Provide the client with a diet high in protein

Rationale :

🔹Protein is critical for the synthesis of collagen and new tissue, which is essential in preventing and healing pressure injuries.

🔹Older adults are at higher risk for malnutrition, which impairs immune response and tissue regeneration.

🔹A high-protein diet supports cell repair, wound healing, and overall skin integrity, especially when combined with adequate hydration and micronutrients like zinc and vitamin C.

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Answer 7

Correct Answers:

Explain to the client what is about to happen

Rationale :

🔵Providing anticipatory guidance during an exam, particularly for older adults, reduces fear, confusion, and the risk of non-cooperation.

🔵Aging is associated with sensory deficits and cognitive slowing, making clear, concise explanations a crucial component of therapeutic communication.

🔵This builds trust, enhances compliance, and supports autonomy in care participation.

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Answer 8

Correct Answers:

I will no longer have a glass of wine before bedtime

Rationale :

👉Although alcohol may initially induce drowsiness, it causes sleep fragmentation, suppresses REM sleep, and increases nocturnal awakenings, particularly in older adults.

👉Avoiding alcohol is a core principle of sleep hygiene, as it supports natural circadian rhythm and promotes restorative sleep.

👉The client’s response indicates an understanding of how lifestyle choices impact sleep quality.

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Answer 9

Correct Answers:

Adjust the bed to an appropriate height

Rationale :

Raising or lowering the bed to match the height of the wheelchair or assistive device facilitates a safe transfer, protecting both the client and the caregiver from injury.
This is essential in clients who can partially bear weight.
Ensuring proper ergonomic alignment is part of safe handling techniques endorsed by OSHA and nursing best practices.

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Answer 10

Correct Answers:

Neutropenic

Rationale :

💥A client who has received an allogeneic hematopoietic stem-cell transplant is at extreme risk for infection due to suppressed bone marrow function and the potential for prolonged neutropenia—a condition characterized by a critically low neutrophil count, which compromises the body’s ability to mount an immune defense.

💥Neutropenic precautions, also known as protective isolation, are essential in protecting these clients from opportunistic infections, including pathogens that are harmless to healthy individuals but can be lethal to immunocompromised patients.

💥This level of precaution is not about preventing transmission from the client, but about protecting the client from external sources, since their immune system is non-functional or severely compromised.

💥Unlike contact, airborne, or droplet precautions—designed to prevent spread to others—neutropenic isolation is protective and focused solely on preventing infection in the client.

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RN Nurs102 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 : 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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