RATIONALE PROVIDED
1.) A nurse is teaching a client who has type 2 diabetes mellitus about foot care. Which of
the following statements by the client indicates an understanding of the teaching?
● I will apply moisturizer between my toes
● I will soak my feet daily
● Ill be sure to wear cotton socks every day
● Ill use a heating pad to warm my feet
Rationale: The nurse should instruct the client to wear clean cotton socks every day to absorb
moisture and reduce the risk of infection.
2.) A nurse is providing discharge teaching for a client who had a left total hip arthroplasty.
Which of the following client statements indicates the teaching was effective?
● I should expect swelling of the affected leg for several weeks
● I should not cross my legs at the ankles or knees
● I will inspect my hip incision every other day for redness
● I can bend over at the hip to pick up objects
Rationale: The nurse should instruct the client to avoid crossing the legs at the knees or ankles
because this can result in the dislocation of the femoral head.
3.) A nurse is providing discharge instructions to a client who has a new laryngectomy. The
nurse should tell the client to be careful while bathing to prevent which of the following
complications?
● Aspiration of water
● Infection of the stoma
● Bleeding around the stoma
● Skin breakdown around the stoma
Rationale: The client should be careful during bathing and showering and should avoid
swimming due to the risk of aspiration of water. The client should use a shower shield over the
stoma when bathing or showering to keep water out of the airway.
4.) A nurse is assessing the hematologic system of an older adult client. The nurse should
report which of the following findings to the provider as a possible indication of a
hematologic disorder?
● Pallor
● Jaundice
● Absence of hair on the legs
● Poor nailbed capillary
Rationale: A progressive loss of hair is common with aging. However, thinning or absence of
hair on the extremities indicates poor arterial circulation to that area. The nurse should look for
, further indications of arterial insufficiency and report these findings to the provider.
5.) A nurse is providing post-procedural teaching to a client who had a diagnostic knee
arthroscopy. Which of the following statements indicates that the client understands the
nurse’s instructions?