1. A nurse in a LTC facility notices a client who has Alzheimer’s disease standing at the exit door at the
end of the hallway. The client appears to be anxious & agitated. What action should the nurse take?
ANSWER: Escort the client to a quiet area on the nursing unit.
- A client c Alzheimer experiences chronic confusion. Guiding the client to a quiet, familiar area will help
decreaseagitation. They will be unable to follow instructions/commands.
2. A nurse is assisting with the plan of care for a client who has a continent urinary diversion. Which
intervention should the nurse plan to implement to facilitate urinary elimination?
ANSWER: Use intermittent urinary catheterization for the client at regular intervals.
- A continent urinary diversion contains valves that prevent urine from exiting the pouch; therefore,
the nurse should plan to insert a urinary catheter at regular intervals to drain urine from the client’s
3. A nurse is assisting with an education program about car restraint safety for a group of parents. Which
statement by the parent indicates an understanding of the instructions?
ANSWER: “My 12YO child should place the shoulder-lap seatbelt low across his hips.”
- When a child is old enough to only use a shoulder-lap seatbelt, he should place it low across his hips
rather thanover the abdomen to reduce risk for injury during motor vehicle crash.
4. A nurse is reinforcing teaching about strategies to promote eating with a client who has
COPD. Whichinstructions should the nurse include in the teaching?
ANSWER: Drink high-protein and high-calorie nutritional supplements.
- The nurse should instruct the client to drink high-protein and high-calorie nutritional supplements to
maintainrespiratory muscle function. COPD causes respiratory stress that leads to hypermetabolism
and wasting of the
client’s muscle mass.
5. When removing PPE after direct care for a client who requires airborne & contact precautions,
which PPE isremoved first?
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