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Questions 164

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Question 1 of 5

The nurse should initiate discharge planning for a client

Correct Answer: C

Rationale: Upon admission to a hospital unit or the emergency room. Early discharge planning ensures continuity of care with shorter hospital stays.

Question 2 of 5

The nurse is caring for a client who has subclavian central venous access. Which nursing intervention is most important to prevent the spread of infection to this client?

Correct Answer: A

Rationale: Frequent hand hygiene is the most effective intervention to prevent infection in central venous access, reducing pathogen transmission. No artificial nails and chlorhexidine wipes are supportive, but hand hygiene is primary. PPE is situational.

Question 3 of 5

The nurse is caring for a client with Meniere's disease. When teaching the client about the disease, the nurse should explain that the client should avoid foods high in

Correct Answer: C

Rationale: Sodium. The client with Meniere's disease has an alteration in the balance of the fluid in the inner ear (endolymph). A low sodium diet will aid in reducing the fluid. Sodium restriction is also ordered as adjunct to diuretic therapy.

Question 4 of 5

A laboring woman prefers to lie in the supine position during labor. The nurse teaches her that this is not a good position for which reason?

Correct Answer: C

Rationale: Supine position can compress the vena cava, causing maternal hypotension and reduced fetal perfusion, leading to fetal heart rate drops.

Question 5 of 5

The nurse is caring for a client who reported having thoughts of self-injury yesterday. Which of the following statements by the client should the nurse recognize as risk factors for suicide? Select all that apply.

Correct Answer: A,C,D,F

Rationale: Unemployment, access to firearms, prior overdose, and hopelessness are established suicide risk factors. Marriage with children and religious activities are protective factors.

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