Hygiene/Skin Integrity
A nurse is teaching a client with type 2 diabetes mellitus about proper foot care. Which statement by the client indicates correct understanding of the teaching?
A. “I should soak my feet in warm water every night to keep them soft.”
B. “I will inspect my feet every day, including between my toes.”
C. “I can trim my toenails by rounding the corners to prevent ingrown nails.”
D. “I should apply lotion generously between my toes to prevent dryness.”
Correct Answer: B
Rationale:
Clients with diabetes are at increased risk for peripheral neuropathy and impaired wound healing. Daily inspection of the feet, including between the toes, helps detect injuries or infections early.
A: Soaking feet is discouraged because it can dry the skin and increase the risk for breakdown.
C: Toenails should be trimmed straight across, not rounded, to prevent injury and ingrown nails.
D: Lotion should not be applied between the toes, as excess moisture can promote fungal infection.
A nurse is assessing the mobility of an older adult client during a physical assessment. Which action best evaluates the client’s ability to ambulate safely?
A. Asking the client if they feel steady when walking
B. Observing the client walk several steps and turn around
C. Assessing muscle strength while the client is lying in bed
D. Checking range of motion of the lower extremities
Observing the client walk allows the nurse to assess gait, balance, coordination, and the need for assistive devices, which are essential for determining safe ambulation.
A: Self-report is subjective and may not reflect actual ability.
C: Muscle strength alone does not fully indicate functional mobility.
D: Range of motion assessment does not evaluate balance or gait safety.
A nurse is assessing urinary elimination in a hospitalized client. Which finding should the nurse recognize as most concerning and requiring further assessment?
A. Urinating 5–6 times per day
B. Pale yellow, clear urine
C. Burning sensation during urination
D. Voiding 300 mL with each urination
Correct Answer: C
Rationale:
A burning sensation during urination (dysuria) is an abnormal finding and may indicate a urinary tract infection or irritation of the urinary tract, requiring further assessment and intervention.
A: Urinating 5–6 times per day is within normal limits for most adults.
B: Pale yellow, clear urine is a normal finding indicating adequate hydration.
D: Voiding approximately 300 mL per urination is within expected range.
A nurse is caring for a confused client who is attempting to remove a nasogastric tube. Which nursing action is most appropriate before applying physical restraints?
A. Apply wrist restraints immediately to prevent tube removal
B. Document the client’s behavior after applying restraints
C. Attempt less restrictive interventions to ensure client safety
D. Obtain a provider’s order after restraints are applied
Correct Answer: C
Rationale:
Restraints are considered a last resort. The nurse must first attempt less restrictive interventions (such as reorientation, distraction, or increased observation) to protect the client’s safety.
A: Restraints should not be applied immediately without attempting alternatives.
B: Documentation is required, but it does not come before attempting alternatives.
D: A provider’s order is required for restraints, but less restrictive measures must be attempted first.
A nurse is preparing to administer a prescribed oral medication to a client. Which action best demonstrates adherence to the “rights” of medication administration?
A. Giving the medication without verifying the client’s identity because it is a routine dose
B. Checking the medication label against the medication administration record (MAR) three times before giving it
C. Crushing all tablets so the client can swallow them easily, regardless of instructions
D. Administering the medication immediately after drawing it up without assessing the client
Correct Answer: B
Rationale:
Verifying the medication against the MAR three times ensures the right drug, dose, route, and time, which is a key step in safe medication administration.
A: The client’s identity must always be verified before administration.
C: Crushing tablets can alter drug absorption or safety; only crush medications if permitted.
D: Assessment of the client and proper timing are critical components of safe medication administration.
A nurse is providing discharge teaching to a client who is prescribed long-term anticoagulant therapy. Which instruction related to skin care and shaving should the nurse include?
A. “Use a straight razor to achieve a closer shave.”
B. “Apply firm pressure if you notice minor bleeding after shaving.”
C. “Use an electric razor when shaving to reduce the risk of cuts.”
D. “Avoid moisturizing lotions because they can thin the skin.”
Correct Answer: C
Rationale:
Clients receiving anticoagulant therapy are at increased risk for bleeding. Using an electric razor reduces the risk of skin cuts and subsequent bleeding.
A: Straight razors increase the risk of cuts and bleeding.
B: Firm pressure may cause tissue damage; gentle pressure is recommended if bleeding occurs.
D: Moisturizing lotions help maintain skin integrity and are generally encouraged.
A nurse is caring for a client who has been on bed rest for several days. Which finding should the nurse recognize as a potential complication of immobility?
A. Increased bone density
B. Orthostatic hypotension
C. Improved venous return
D. Increased appetite
Rationale:
Prolonged immobility can lead to orthostatic hypotension due to decreased venous return and reduced cardiovascular reflexes when changing positions.
A: Immobility leads to decreased, not increased, bone density.
C: Venous stasis occurs with immobility, increasing the risk for thrombus formation.
D: Appetite often decreases with prolonged bed rest.
A nurse is assessing a client who reports involuntary urine leakage when coughing and laughing. Which type of urinary incontinence does the nurse suspect?
A. Urge incontinence
B. Overflow incontinence
C. Stress incontinence
D. Functional incontinence
Correct Answer: C
Rationale:
Stress incontinence is characterized by urine leakage during activities that increase intra-abdominal pressure, such as coughing, laughing, or sneezing.
A: Urge incontinence involves a sudden, intense urge to urinate followed by involuntary loss of urine.
B: Overflow incontinence is caused by bladder overdistention and incomplete emptying.
D: Functional incontinence occurs when physical or cognitive impairments prevent timely toileting despite normal urinary function.
A nurse is caring for a client placed in soft wrist restraints for safety. Which nursing action is most important to include in the client’s plan of care?
A. Remove the restraints every 8 hours
B. Check circulation, skin integrity, and range of motion regularly
C. Keep the restraints applied until the provider discontinues the order
D. Tie the restraints to the side rail of the bed
Correct Answer: B
Rationale:
When restraints are used, the nurse must frequently assess circulation, skin integrity, and range of motion to prevent injury and complications such as impaired circulation or skin breakdown.
A: Restraints should be released more frequently than every 8 hours (typically at least every 2 hours, per policy).
C: Restraints should be removed as soon as they are no longer necessary, not simply kept on until the order expires.
D: Restraints should be tied to the bed frame, not the side rails, to prevent injury.
A nurse is preparing to give a client a prescribed oral medication. Which action is most important before administering the medication?
A. Crushing the tablet to make it easier to swallow without checking instructions
B. Asking the client if they have any allergies to medications
C. Giving the medication immediately before meals, regardless of instructions
D. Pouring the medication directly from the bottle into the client’s hand
Correct Answer: B
Rationale:
Assessing for medication allergies is a critical safety step before any drug administration to prevent adverse reactions.
A: Tablets should only be crushed if it is safe for that specific medication.
C: The timing of oral medications should follow provider instructions, especially regarding meals.
D: Medications should always be poured into a medication cup, not the client’s hand, to ensure correct dosing.
A nurse is caring for a bedbound client who is at high risk for impaired skin integrity. Which nursing intervention is most effective in preventing pressure injuries?
A. Keeping the head of the bed elevated at all times
B. Repositioning the client at least every 2 hours
C. Massaging reddened bony prominences
D. Using powder to keep the skin dry
Correct Answer: B
Rationale:
Regular repositioning at least every 2 hours reduces prolonged pressure on bony prominences, promotes circulation, and is a key intervention in preventing pressure injuries in bedbound clients.
A: Keeping the head of the bed elevated increases pressure and shear on the sacrum.
C: Massaging reddened areas can damage tissue and worsen skin breakdown.
D: Powder may cake on the skin and cause irritation; moisture management should be done with appropriate barrier products.
A nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who has decreased mobility and an ineffective cough. Which complication is the client most at risk for?
A. Atelectasis
B. Pulmonary embolism
C. Hypertension
D. Pneumothorax
In clients with COPD, decreased mobility combined with an ineffective cough leads to retained secretions, which can obstruct airways and cause atelectasis.
B: Pulmonary embolism is associated with immobility but not directly caused by ineffective coughing.
C: Hypertension is not related to ineffective cough or secretion retention.
D: Pneumothorax is not a common complication of ineffective coughing.
A nurse is assessing bowel elimination in an adult client. Which finding should the nurse identify as abnormal and requiring further assessment?
A. Passing a soft, formed stool every other day
B. Straining and passing hard, dry stools
C. Brown-colored stool with mild odor
D. Passing flatus daily
Correct Answer: B
Rationale:
Straining and passing hard, dry stools indicate constipation, which can lead to complications such as hemorrhoids, fecal impaction, and vagal stimulation.
A: A soft, formed stool every other day can be normal bowel elimination.
C: Brown-colored stool is a normal finding related to bile.
D: Passing flatus daily indicates normal gastrointestinal function.
A nurse receives an order to administer haloperidol IM as a chemical restraint for a severely agitated client who is attempting to harm staff. Which nursing action is most appropriate before administering the medication?
A. Apply physical restraints to the client immediately
B. Verify that less restrictive interventions have been attempted
C. Administer the medication as a routine PRN sedative
D. Delay administration until a family member provides consent
Correct Answer: B
Rationale:
Chemical restraints are medications used to control behavior, not treat a medical condition, and should be used only after less restrictive interventions have failed. The nurse must ensure the order is appropriate and that alternatives (such as de-escalation or environmental modifications) were attempted.
A: Physical restraints are not automatically required before chemical restraints and should also be a last resort.
C: Chemical restraints are not routine PRN medications and require careful justification and monitoring.
D: In an emergency situation where the client poses immediate danger, consent from family is not required before administering a chemical restraint.
A nurse is preparing to administer a prescribed intramuscular (IM) antibiotic to a client. Which action should the nurse take first?
A. Clean the injection site with alcohol and administer the medication
B. Ask the client about any known allergies to medications
C. Draw the medication into the syringe and recap it
D. Apply a bandage after giving the injection
Correct Answer: B
Rationale:
Before administering any medication, including IM injections, the nurse must assess for allergies to prevent life-threatening reactions such as anaphylaxis.
A: Site preparation and administration come after confirming there are no allergies.
C: Medication should be prepared carefully, but allergy assessment must come first.
D: Applying a bandage occurs after the injection and does not take priority over safety checks.
A nurse is teaching a hospitalized client about proper oral hygiene. Which instructions should the nurse include? Select all that apply.
A. Brush teeth at least twice daily using a soft-bristled toothbrush
B. Use alcohol-based mouthwash after every meal
C. Clean the tongue gently during oral care
D. Replace the toothbrush every 3–4 months
E. Perform oral care at least once per shift if the client is unable to do so independently
Correct Answers: A, C, D, E
Rationale:
A: A soft-bristled toothbrush helps prevent gum injury while effectively removing plaque.
C: Cleaning the tongue reduces bacteria and helps prevent halitosis and infection.
D: Toothbrushes should be replaced every 3–4 months or sooner if bristles are frayed.
E: Dependent clients require regular oral care to maintain mucosal integrity and prevent infection.
B: Alcohol-based mouthwashes can dry and irritate oral mucosa and are not recommended for frequent use.
A nurse is teaching a client how to safely use crutches for ambulation. Which instructions should the nurse include? Select all that apply.
A. Support body weight on the hands, not the axillae
B. Position crutches 6 to 10 inches diagonally in front of the foot.
C. Keep the elbows slightly flexed when holding the handgrips
D. Allow the tops of the crutches to rest firmly in the axillae
E. Look down at the feet while walking to maintain balance
Correct Answers: A, B, C
Rationale:
A: Weight should be borne through the hands to prevent axillary nerve damage.
B: Proper crutch placement improves balance and stability during ambulation.
C: Slight elbow flexion (about 20–30 degrees) allows effective weight bearing and control.
D: Resting crutches in the axillae can cause nerve injury and impaired circulation.
E: Clients should look forward, not down, to maintain posture and balance.
A nurse is providing teaching to a client who recently had a sigmoid colostomy. Which statement by the client indicates correct understanding of colostomy care?
A. “My stoma should appear pale and bluish in color.”
B. “I should notify my provider if the stoma becomes dark or black.”
C. “I will irrigate my colostomy daily regardless of my provider’s instructions.”
D. “I should expect the stoma to be painful when touched.”
Correct Answer: B
Rationale:
A healthy colostomy stoma should be moist and pink to red in color. A dark, purple, or black stoma may indicate compromised blood flow and requires immediate notification of the healthcare provider.
A: A pale or bluish stoma is abnormal and suggests poor perfusion.
C: Colostomy irrigation is not appropriate for all clients and should only be done if prescribed.
D: The stoma has no nerve endings and should not be painful when touched.
A nurse receives a provider’s order to administer lorazepam IV as a chemical restraint for an acutely agitated client who is at risk of harming others. Which action should the nurse take first?
A. Administer the medication as ordered to quickly control the behavior
B. Assess and document the client’s behavior and risk for harm
C. Apply soft wrist restraints before giving the medication
D. Obtain written informed consent from the client’s family
Correct Answer: B
Rationale:
Before administering a chemical restraint, the nurse must assess and document the client’s behavior, level of agitation, and risk for harm, and verify that the medication is being used for behavior control rather than routine treatment. Ongoing monitoring and documentation are required.
A: The medication should not be given without proper assessment and documentation.
C: Physical restraints are not required before administering a chemical restraint.
D: In emergency situations, consent from family is not required when the client poses an immediate danger.
A nurse is initiating IV fluid therapy for a client. Which action is most important to ensure safe IV fluid administration?
A. Verifying the type and rate of IV fluid against the provider’s order
B. Flushing the IV line after every shift regardless of the type of fluid
C. Hanging the IV bag without checking the expiration date
D. Taping the IV tubing securely to the client’s skin without inspecting the site
Correct Answer: A
Rationale:
Verifying the type and rate of IV fluid against the provider’s order ensures the right fluid, right rate, and right patient, which is essential for safe IV therapy.
B: Flushing is important but should follow protocol and after assessing compatibility, not automatically.
C: Expiration dates must always be checked before administration.
D: IV site should be inspected for redness, swelling, or infiltration before securing the tubing.
A nurse is assessing a client’s surgical wound. Which findings indicate normal drainage and healing? Select all that apply.
A. Small amount of serous (clear or slightly yellow) drainage
B. Bright red, large-volume drainage soaking the dressing
C. Edges of the wound approximated with minimal swelling
D. Slight tenderness around the wound site
E. Presence of foul odor or thick green drainage
Correct Answers: A, C, D
Rationale:
A: Small amounts of serous drainage are typical during the early stages of healing.
C: Wound edges that are approximated with minimal swelling indicate proper healing.
D: Mild tenderness is expected due to tissue repair and inflammation.
B: Large amounts of bright red drainage indicate hemorrhage, which is abnormal.
E: Foul-smelling or purulent drainage suggests infection and requires prompt intervention.
A nurse is teaching a client how to use a cane safely. Which instructions should the nurse include? Select all that apply.
A. Hold the cane on the unaffected side of the body
B. Move the cane at the same time as the affected leg
C. Keep the cane about 4–6 inches to the side of the foot
D. Place all weight on the cane while walking
E. Keep elbows slightly flexed when holding the cane
Correct Answers: A, B, C, E
Rationale:
A: Holding the cane on the stronger side provides better support and balance.
B: Proper gait with a cane involves moving the cane first, then the weaker leg, then the stronger leg.
E: Slight elbow flexion (about 15–30 degrees) allows for better support and reduces strain.
C: The cane should stay 4-6 inches from the side of the foot.
D: The cane is meant to provide support, not bear all body weight.
A nurse is caring for a client with an indwelling Foley catheter. Which nursing interventions help prevent catheter-associated urinary tract infection (CAUTI)? Select all that apply.
A. Perform perineal care daily and after bowel movements
B. Keep the drainage bag below the level of the bladder
C. Disconnect the catheter from the drainage tubing to obtain urine samples
D. Secure the catheter to the client’s thigh
E. Empty the drainage bag using a clean container for each client
Correct Answers: A, B, D, E
Rationale:
A: Regular perineal care reduces the risk of bacterial migration into the urinary tract.
B: Keeping the drainage bag below bladder level prevents backflow of urine.
D: Securing the catheter prevents traction and urethral trauma.
E: Using a clean, dedicated container helps prevent cross-contamination.
C: The closed drainage system should remain intact; urine samples should be obtained from the sampling port using aseptic technique.
A nurse is caring for a client who is placed in physical restraints for safety. Which nursing actions are appropriate while the client is restrained? Select all that apply.
A. Assess circulation and skin integrity at least every 2 hours
B. Remove restraints periodically to provide range-of-motion exercises
C. Tie the restraints to the bed’s side rails
D. Ensure the restraints can be easily released in an emergency
E. Document the client’s behavior and need for continued restraint use
Correct Answers: A, B, D, E
Rationale:
A: Frequent assessment of circulation and skin integrity helps prevent injury.
B: Restraints should be removed regularly to allow range of motion, repositioning, and basic needs.
D: Restraints must be secured with a quick-release knot for safety.
E: Ongoing documentation is required to justify continued restraint use.
C: Restraints should be tied to the bed frame, not side rails, to prevent injury if the bed is raised or lowered.
A nurse is caring for a client receiving IV fluid therapy. Which interventions are appropriate to ensure safe IV fluid administration? Select all that apply.
A. Verify the provider’s order for type, rate, and volume of IV fluid
B. Check the IV site for redness, swelling, or pain before starting infusion
C. Monitor the client’s intake and output and daily weight
D. Hang the IV bag without checking for leaks or expiration date
E. Adjust the IV flow rate as needed based on the client’s assessment and order
Correct Answers: A, B, C, E
Rationale:
A: Confirming the order ensures the correct fluid and rate are given.
B: Assessing the IV site prevents complications such as infiltration or phlebitis.
C: Monitoring I&O and daily weight helps identify fluid overload or deficit.
E: Flow rate adjustments may be required based on client condition or provider instructions.
D: IV bags must always be checked for integrity, leaks, and expiration before administration.