1. A 20-year-old female client with a noticeable body odor has refused to shower for the last 3 days. She states, "I have been told that it is harmful to bathe during my period." Which action should the nurse take first?
A. Accept and document the client's wish to refrain from bathing.
B. Offer...
1. A 20-year-old female client with a noticeable body odor has refused to shower for
the last 3 days. She states, "I have been told that it is harmful to bathe during my
period." Which action should the nurse take first?
A. Accept and document the client's wish to refrain from bathing.
B. Offer to give the client a bed bath, avoiding the perineal area.
C. Obtain written brochures about menstruation to give to the client.
D. Teach the importance of personal hygiene during menstruation with the client.: D
Rationale: Because a shower is most beneficial for the client in terms of hygiene, the client
should receive teaching first, respecting any personal beliefs such as cultural or spiritual values.
After client teaching, the client may still choose option A or B. Brochures reinforce the teaching.
2. A 65-year-old client who attends an adult daycare program and is wheelchair-
mobile has redness in the sacral area. Which instruction is most important for the
nurse to provide?
A. Take a vitamin supplement tablet once a day.
B. Change positions in the chair at least every hour.
C. Increase daily intake of water or other oral fluids.
D. Purchase a newer model wheelchair.: B
Rationale: The most important teaching is to change positions frequently because pressure is the
most significant factor related to the development of pressure ulcers. Increased vitamin and fluid
intake may also be beneficial and promote healing and reduce further risk. Option D is an
intervention of last resort because this will be very expensive for the client.
3. After a needle stick occurs while removing the cap from a sterile needle,
which action should the nurse implement?
D. Notify the supervisor of the department immediately.: B
Rationale: After a needle stick, the needle is considered used, so the nurse should discard it and
select another needle. Because the needle was sterile when the nurse was stuck and the needle
was not in contact with any other person's body fluids, the nurse does not need to complete an
incident report or notify the occupational health nurse. Disinfecting a needle with an alcohol
swab is not in accordance with standards for safe practice and infection control.
4. After receiving written and verbal instructions from a clinic nurse about a newly
prescribed medication, a client asks the nurse what to do if questions arise about
the medication after getting home. How should the nurse respond?
A. Provide the client with a list of Internet sites that answer frequently
asked questions about medications.
B. Advise the client to obtain a current edition of a drug reference book from
a local bookstore or library.
C. Reassure the client that information about the medication is included in
the written instructions.
D. Encourage the client to call the clinic nurse or health care provider if
any questions arise.: D
Rationale: To ensure safe medication use, the nurse should encourage the client to call the
nurse or health care provider if any questions arise. Options A, B, and C may all include
useful information, but these sources of information cannot evaluate the nature of the client's
questions and the follow-up needed.
5. After the nurse tells an older client that an IV line needs to be inserted, the client
becomes very apprehensive, loudly verbalizing a dislike for all health care providers
and nurses. How should the nurse respond?
A. Ask the client to remain quiet so the procedure can be performed safely.
B. Concentrate on completing the insertion as efficiently as possible.
C. Calmly reassure the client that the discomfort will be temporary.
D. Tell the client a joke as a means of distraction from the procedure.: C
Rationale: The nurse should respond with a calm demeanor to help reduce the
client's
apprehension. After responding calmly to the client's apprehension, the nurse may implement to
ensure safe completion of the procedure.
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