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Questions 148

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Extract:


Question 1 of 5

The newly graduated nurse is caring for an elderly client on the medical-surgical floor. The nurse recalls learning about client advocacy. Which actions by the nurse indicate an understanding of client advocacy? Select all that apply.

Correct Answer: C,D,E

Rationale: Ensuring understanding of treatment options, obtaining an interpreter, and discussing advance directives promote client autonomy and rights. Other actions assume incapacity or impose personal views.

Question 2 of 5

Which assignment should not be performed by the nursing assistant?

Correct Answer: D

Rationale: Administering an enema is an invasive procedure requiring clinical judgment, which is beyond the scope of a nursing assistant's responsibilities.

Question 3 of 5

The nurse is teaching the mother of an infant with eczema. Which of the following instructions should be included in the nurse's teaching?

Correct Answer: B

Rationale: Cutting nails regularly prevents scratching, which can worsen eczema and lead to infections in affected skin areas.

Question 4 of 5

The nurse is caring for a newborn who is on strict intake and output. The used diaper weighs $73.5 \mathrm{gm}$. The diaper's dry weight was $62 \mathrm{gm}$. The newborn's urine output is:

Correct Answer: B

Rationale: Urine output is calculated by subtracting dry diaper weight from wet diaper weight: 73.5 gm - 62 gm = 11.5 ml (1 gm = 1 ml for urine).

Question 5 of 5

The nurse is assessing a client with suspected meningitis. Which of the following findings would the nurse expect?

Correct Answer: A

Rationale: positive Kernig’s sign (pain and resistance on leg extension) is a classic finding in meningitis

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