The nurse should wash from the ________________________ when washing a patient's eye area.

Correct Answer: B

Rationale: When washing a patient's eye area, it is important to start from the inner canthus (closest to the nose) and move towards the outer canthus. This direction prevents any contaminants or debris from the outer area of the eye from moving towards the inner, more sensitive area. Choices C and D are incorrect as they pertain to the nasal passages (nares), which are not relevant when washing the eye area.

Correct Answer: D

Rationale: A nurse can promote sleep for a client experiencing insomnia by addressing factors that may hinder sleep. Cold feet can disrupt sleep, so providing the client with socks to keep their feet warm can enhance comfort and aid in promoting sleep. The correct answer focuses on a direct intervention to address a specific issue that can impact sleep quality. Choices A, B, and C do not directly address the issue of cold feet, which is a common problem that can interfere with sleep in individuals with insomnia. Assisting the client to use the bathroom, giving a massage in the morning, or tucking in bed sheets tightly do not target the discomfort caused by cold feet, making them less effective interventions for promoting sleep in this scenario.

Correct Answer: A

Rationale: The correct answer is A: D/C. D/C is not an acceptable abbreviation as it can be easily confused with both 'discharge' and 'discontinue.' The abbreviations 'tid' (three times a day), 'bid' (twice a day), and 'qid' (four times a day) are commonly used in medical contexts to indicate dosing frequencies and are widely accepted in healthcare settings.

Correct Answer: D

Rationale: The lowest priority patient care task in this scenario is addressing the emotional need of the patient who is crying because his daughter did not visit him today. While emotional support is important, the other needs - providing water, assisting to the bathroom, and addressing chest pain - are physical needs that must take priority as they directly impact the patient's well-being and health. It is crucial to acknowledge and address emotional needs but in this situation, the physical needs of the patients should be addressed first.

Correct Answer: C

Rationale: When a client with a colostomy is preparing for irrigation, it is essential to consider contraindications that could pose risks or worsen the client's condition. Diverticulitis is a contraindication for colostomy irrigation because the inflamed diverticula could be further irritated by the flushing action during irrigation, potentially leading to complications. An incontinent ostomy, irregular bowel routine, or presence of fecal material in the colostomy bag are not specific contraindications for irrigation and can be managed through appropriate techniques and interventions.

Correct Answer: D

Rationale: When performing closed intermittent system catheter irrigation, the nurse should use sterile solution at room temperature with sterile technique. It is important to position the client comfortably for easy access to the catheter site and to assess the abdomen during the procedure. Clamping the catheter should be done below the level of the injection port, not above. The correct step is to inject sterile solution through the injection port into the catheter, allowing the fluid to travel up the catheter to irrigate the tubing and the bladder.

Correct Answer: A

Rationale: The Sims' position is a side-lying position used for examinations or comfort. In the Sims' position, the client lies on their side with the upper leg flexed. The abdomen is slightly downward, and the lower arm is positioned behind the body. A pillow can be used to support the leg. Choice B is incorrect as it describes a position with the client lying on their back with the head lower than the feet. Choice C is incorrect as it describes a prone position, not the Sims' position. Choice D is incorrect as it describes a sitting position, not the Sims' position.

Correct Answer: A

Rationale: No, there is nothing else that a nurse should do. A temperature of 98.5 degrees for an elderly patient falls within normal limits. Other choices are incorrect because the temperature is not hyperthermic (abnormally high) or hypothermic (abnormally low), making choices B, C, and D inaccurate responses in this scenario.

Correct Answer: A

Rationale: The correct answer is to postpone bowel movement when the urge to defecate occurs. Clients who delay bowel movements by ignoring the urge to defecate or not evacuating promptly, such as in situations where they are not near a bathroom, are at higher risk of developing constipation. This behavior leads to a decrease in bowel movement frequency, slowed intestinal motility, and increased fecal water absorption, resulting in hard, dry stools that are difficult to pass. Intestinal infection (choice B), antibiotic use (choice C), and food allergies (choice D) are less likely to be direct causes of constipation compared to postponing bowel movements.