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Question 1 of 5

On a home health visit, an elderly client states, 'This neighborhood has really gone down. I feel like a prisoner in my own home with all the trouble out there.' Which of the following nursing responses by the nurse is BEST?

Correct Answer: D

Rationale: assessing the basis for client's fears and encouraging client to talk about them is the first positive step

Question 2 of 5

The nurse is performing an ice massage for a client in chronic pain. The nurse is MOST concerned if which of the following is observed?

Correct Answer: B

Rationale: Mottling or graying indicates potential frostbite or tissue damage, a serious concern requiring immediate cessation of ice massage. Options A, C, and D are less critical: redness is common, burning/tingling suggests ischemia, and numbness/cold is expected.

Question 3 of 5

The nurse is caring for a client who is postoperative day 2 after a bowel resection. Which of the following findings would be of GREATest concern to the nurse?

Correct Answer: A

Rationale: Absence of bowel sounds on postoperative day 2 may indicate paralytic ileus or obstruction, a serious complication requiring immediate evaluation. Options B, C, and D are expected or normal: slight fever is common, incision pain is typical, and urine output is adequate.

Question 4 of 5

An abdominal wound irrigation with a normal saline solution is ordered for a client. To perform this procedure, the nurse should

Correct Answer: B

Rationale: requires strict aseptic technique

Question 5 of 5

A client is receiving a blood transfusion. Fifteen minutes after the transfusion begins, the client develops a fever and chills. Which of the following actions should the nurse take FIRST?

Correct Answer: A

Rationale: fever and chills may indicate a transfusion reaction, and the transfusion must be stopped immediately

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