Correct Answer: B

Rationale: Empty the urine drainage bag every 12 hours: While it’s essential to empty the urine drainage bag regularly to prevent it from becoming too full, emptying it every 12 hours alone is not sufficient to prevent urinary tract infections (UTIs). Drain the urine from the tubing before ambulation: Correct. Before the client ambulates or moves, the nurse should ensure that the urinary catheter’s tubing is emptied. This prevents urine from flowing back into the bladder, reducing the risk of UTIs. Use clean technique for urine specimen collection: While using clean technique during urine specimen collection is important for preventing contamination, it is not the primary action needed to prevent UTIs in a client with an indwelling urinary catheter. Hang the urine drainage bag at the level of the bladder: While proper positioning of the drainage bag is essential for optimal urine flow and to prevent backflow, it alone is not sufficient to prevent UTIs.

Correct Answer: A

Rationale: Applying thromboembolic stockings (compression stockings) to the client's legs is a task that can be safely delegated to assistive personnel. The nurse should provide clear instructions on how to apply them properly. Incorrect. Monitoring the circulation in all four extremities requires clinical judgment and skilled assessment, and it should not be delegated to assistive personnel. Incorrect. Recording the condition of the client's skin requires observation and assessment, which should not be delegated to assistive personnel.

Correct Answer: B

Rationale: Standing facing the center of the bed at the client’s side allows the nurse to maintain proper body mechanics and use their body weight to assist in moving the client. Placing feet apart with the foot nearest the head of the client’s bed in front of the other foot also helps the nurse maintain stability and leverage while moving the client. Keeping knees and hips straight while bending at the waist toward the client is incorrect body mechanics and can put a strain on the nurse’s back. Encouraging the client to keep their legs straight and remain still is not appropriate. The client should be actively involved in the movement, assisting as much as possible, to ensure their safety and cooperation.

Correct Answer: D

Rationale: Show the assistive personnel where to apply the medication: This action is not appropriate because only licensed healthcare providers, such as nurses, are allowed to administer medications. Ask the client when the previous nurse last applied the medication: While communication with the client is important, it is not a reliable method to verify medication administration accuracy. Identify the client by comparing the medication administration record with the client’s room number: This action is insufficient to verify the correct client because there could be multiple clients with the same medication due. Compare the label of the medication container with the medication administration record three times: Correct. This action is known as the 'three checks' and is an essential step in medication administration. The nurse should compare the medication label with the medication administration record before removing the medication, after removing the medication, and at the bedside before administering the medication.

Correct Answer: C

Rationale: Allowing the client to continue taking medications as they did at home without verifying the prescriptions can be unsafe and is not within the scope of nursing practice. Taking the medications from the client and discarding them is inappropriate. The nurse should not dispose of the client's medications without proper assessment and verification. Correct. The nurse should compare the medications the provider has prescribed with the medications the client brought from home to ensure accuracy and safety. This is a crucial step during admission to prevent errors or omissions in the medication regimen. Placing the medications in the medication cart and administering them without verification is unsafe and against best practices for medication administration.