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1. A nurse is reinforcing discharge teaching about wound care with a family member of a
client who is postoperative. Which of the following should the nurse include in the teaching?
a) Administer an analgesic following wound care. (The nurse should remind the family
member to administer an analgesic prior to wound care to prevent discomfort.)
b) Irrigate the wound with povidone iodine. (The nurse should remind the family member to
irrigate the wound with 0.9% sodium chloride.)
c) Cleanse the wound with a cotton-tipped applicator. (The nurse should remind the family
member to avoid using a cotton-tipped applicator to cleanse the wound because the fibers
can become embedded in the wound, cause infection, and delay wound healing.)
d) Report purulent drainage to the provider. (The nurse should remind the family member to
report signs of infection, including purulent drainage.)
2. A nurse is caring for a client who has bacterial meningitis. Upon monitoring the client,
which of the following findings should the nurse expect?
a) Flaccid neck (The nurse should recognize that nuchal rigidity, rather than a flaccid neck,
is a manifestation of meningitis.)
b) Stooped posture with shuffling gait (The nurse should recognize that a stooped posture
with shuffling gait is a manifestation of Parkinson's disease, not a manifestation of
meningitis.)
c) Red macular rash (The nurse should expect to find a red macular rash, sometimes called a
petechial rash, which is a manifestation of meningococcal meningitis.)
d) Masklike facial [removed]The nurse should recognize that a masklike expression is a
manifestation of Parkinson's disease, not a manifestation of meningitis.)
3. A nurse is contributing to the plan of care for an older adult client who is at risk for
osteoporosis. Which of the following interventions should the nurse include to prevent bone
loss?
a) Increase fluid intake. (Fluid intake is beneficial for general health and wellness, and it
helps to treat some disorders. Caffeine and alcohol intake can increase the client's risk of
developing osteoporosis. However, fluid intake does not prevent bone loss.)
b) Encourage range-of-motion exercises. (Range-of-motion exercises are beneficial for
general health and wellness, and they help to maintain flexibility and prevent
contractures. However, range-of-motion exercises do not prevent bone loss.)
c) Massage bony prominences. (Massaging bony prominences should be avoided because it
can traumatize deep tissues.)
d) Encourage weight-bearing exercises. (Weight-bearing exercises, such as walking, can
maintain bone mass by reducing bone demineralization, thus helping to prevent
osteoporosis.)
4. A nurse is collecting data from a client and notices several skin lesion. Which of the
following findings should the nurse report as possible melanoma?
a) Scaly patches (The nurse should report scaly patches as possible basal or squamous cell
carcinoma.
b) Silvery white plaques (The nurse should report silvery white plaques as possible
psoriasis.)
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