Choice A rationale: The stool test for occult blood is not primarily designed to detect bacteria.
Choice B rationale: Parasites are not typically detected through a stool test for occult blood.
Choice C rationale: Steatorrhea refers to the presence of excess fat in the stool and is not the primary focus of a stool test for occult blood.
Choice D rationale: The purpose of the stool test for occult blood is to check for the presence of blood in the stool, which may not be visible to the naked eye. This can be an indicator of gastrointestinal bleeding.

Choice A rationale: A client who is confined to bedrest may not need a gait belt as they are not ambulating.
Choice B rationale: A client with leg strength who can cooperate with movement is a likely candidate for a gait belt. This device provides support and stability during ambulation.
Choice C rationale: A client with a thoracic incision may not necessarily need a gait belt for ambulation unless there are specific mobility concerns.
Choice D rationale: A client with an abdominal incision may not necessarily need a gait belt for ambulation unless there are specific mobility concerns.

Choice A rationale: The client who is 92 years old, uses a walker, is incontinent, and has an extensive cardiac history is at higher risk for the development of pressure injuries due to age, immobility, and additional risk factors.
Choice B rationale: A client with paraplegia may be at risk for pressure injuries, but the combination of age, walker use, incontinence, and cardiac history increases the risk in Choice A.
Choice C rationale: A comatose client with a traumatic brain injury is at risk, but other factors in Choice A contribute to a higher overall risk.
Choice D rationale: A client who uses a cane and has dementia may be at risk, but the combination of age, walker use, incontinence, and cardiac history increases the risk in Choice A.

Choice A rationale: Decubitus ulcers (pressure ulcers) are not directly prevented by applying padded boots for dorsiflexion.
Choice B rationale: Applying padded boots for dorsiflexion helps prevent foot drop, a condition where the foot is permanently in a plantar-flexed position, which can lead to contractures.
Choice C rationale: Pooling of blood is not a primary concern addressed by applying padded boots for dorsiflexion.
Choice D rationale: Blood pressure changes are not directly addressed by applying padded boots for dorsiflexion.

Choice A rationale: Polyuria refers to excessive production of urine, so "Inadequate elimination of urine" is not an accurate description.
Choice B rationale: Polyuria does not mean the absence of urine; rather, it implies an increased urinary volume.
Choice C rationale: Polyuria is not related to difficult or uncomfortable voiding.
Choice D rationale: Polyuria is characterized by greater than normal urinary volume, so this is the correct description.

The total volume is divided by the total time

=750/8

=93.75 ml/hr

= 94 ml/hr (rounded off to the nearest whole number)

Choice A rationale: Elevating the head of the bed is not the recommended action when moving a client up in bed.
Choice B rationale: Having the client fold the arms across the chest is not the primary action when moving a client up in bed.
Choice C rationale: Asking another nurse about the plan of care is not necessary in this situation and does not directly address the action needed when moving the client.
Choice D rationale: Maintaining a pillow under the client's head helps provide comfort and support during the movement.

Choice A rationale: Voiding and discarding the urine is the first step in a 24-hour urine collection to ensure that the collection starts with a fresh specimen.
Choice B rationale: Adding the first voiding to the specimen is not the correct initial step.
Choice C rationale: Keeping the urine warm during collection is important, but it is not the first step in the process.
Choice D rationale: Beginning the collection at a specific time is part of the process but not the initial step.

Choice A rationale: Carrying an air-filled ball while wading through the water across the width of a pool is an isotonic exercise.
Choice B rationale: Contracting the gluteal muscles while holding a simple yoga pose is an isometric exercise.
Choice C rationale: Walking at a rate of 3 miles (5 km)/hour around a racetrack is an isotonic exercise.
Choice D rationale: Sitting in a chair with a low weight on the side and lifting the knee to the seat level of the chair is an isotonic exercise.

Choice A rationale: Stool expelled into an ileostomy bag is often of liquid consistency. An ileostomy involves the diversion of the small intestine, where the stool is more liquid compared to a colostomy, which involves the large intestine and typically produces more formed stool.
Choice B rationale: Bloody stool is not a typical characteristic of stool from an ileostomy.
Choice C rationale: Mucus-filled stool is not the primary characteristic of stool from an ileostomy.
Choice D rationale: Soft semi-formed stool is not typical of an ileostomy; the stool is more liquid in consistency.

Choice A rationale: Protective supine positioning is not ideal for managing dysphagia or facilitating swallowing.
Choice B rationale: Semi-Fowlers positioning, with the head of the bed elevated at a 30 to 45-degree angle, is often recommended for clients with dysphagia. This position helps prevent aspiration during eating and promotes effective swallowing.
Choice C rationale: Low-Fowlers and Fowlers positions may not be as effective in preventing aspiration during eating as the Semi-Fowlers position.
Choice D rationale: Fowlers positioning alone may not be sufficient for managing dysphagia; Semi-Fowlers is a more specific recommendation.

Choice A rationale: The statement "I need to void after sexual intercourse to flush microorganisms away from my urethra" is correct. Voiding after sexual intercourse can help prevent the ascent of microorganisms into the urethra and reduce the risk of urinary tract infections.
Choice B rationale: Wearing snug-fitting pants can contribute to a warm and moist environment, potentially increasing the risk of urinary tract infections rather than preventing them.
Choice C rationale: Wiping from the anus to the vagina after going to the bathroom can introduce microorganisms into the urethral area, increasing the risk of urinary tract infections.
Choice D rationale: Frequent bubble baths can disrupt the natural balance of microorganisms in the genital area and increase the risk of urinary tract infections.

Choice A rationale: Stage I pressure ulcers consist of non-blanching erythema with an intact epidermis unlike in the above picture.
Choice B rationale: This is correct since Stage II pressure ulcers involve partial-thickness skin loss but do not extend into the deeper layers as shown in the image above.
Choice C rationale: Stage IV pressure ulcers involve full-thickness tissue loss with exposed muscle, bone, or other structures.
Choice D rationale: Stage III pressure ulcers involve full-thickness tissue loss with visible fat but do not extend to the underlying muscle.

Volume= dose/concentration

= 12/15

= 0.8 mL

Choice A rationale: Using the axilla to bear body weight can lead to nerve damage and is not a proper crutch technique.
Choice B rationale: Keeping the elbows extended can lead to discomfort and poor crutch control. The elbows should be slightly flexed.
Choice C rationale: When getting up from a chair, extending the uninjured leg first is not the correct technique. The patient should keep the injured leg extended for stability.
Choice D rationale: Placing weight on the unaffected leg first when climbing stairs is the correct technique, allowing for better balance and stability.

Choice A rationale: Redness, warmth, swelling, and green drainage are not typically signs of anemia.
Choice B rationale: These symptoms are indicative of infection. Infections can cause localized redness, warmth, swelling, and the drainage of discolored material.
Choice C rationale: While wound healing may involve some inflammation, the described symptoms are more consistent with infection than normal wound healing.
Choice D rationale: Necrosis involves tissue death and is not typically associated with redness, warmth, and swelling.

Choice A rationale: Stress incontinence is characterized by involuntary urine leakage during activities that increase intra-abdominal pressure, such as coughing or sneezing.
Choice B rationale: Transient incontinence is temporary and often related to factors like medications or medical conditions.
Choice C rationale: Total incontinence refers to continuous and unpredictable leakage of urine.
Choice D rationale: Reflex incontinence is associated with neurologic dysfunction, and the lack of warning or stress preceding involuntary urination aligns with this description.

Choice A rationale: Wound healing by first intention involves the approximation of wound edges, often closed with sutures or staples, resulting in minimal scar formation.
Choice B rationale: Contamination at the time of injury is not characteristic of wounds healing by first intention.
Choice C rationale: Granulation tissue forming at the bottom of the wound bed is characteristic of wounds healing by second intention, not first intention.
Choice D rationale: Healing of the wound is typically quicker and involves less scarring in wounds healing by first intention compared to second intention.

Choice A rationale: If the client's skin becomes red, the heat application should be stopped to prevent burns or skin damage.
Choice B rationale: Heat applications are generally recommended for 20-30 minutes, not at least 40 minutes, to avoid skin damage.
Choice C rationale: Safety pins should not be used to keep the heating pad in place, as they can damage the pad or cause injury to the client.
Choice D rationale: The temperature of the heating pad should be set to a comfortable and safe level, typically below 42.2° C (108° F).

Choice A rationale: The skin helps regulate body temperature by sweating and dilation or constriction of blood vessels.
Choice B rationale: The skin acts as a barrier, protecting the body from external threats such as pathogens and physical injury.
Choice C rationale: The skin is rich in sensory receptors, allowing for the perception of touch, pressure, pain, and temperature.
Choice D rationale: The skin plays a role in the production of vitamin D when exposed to sunlight.
Choice E rationale: Vitamin C production is not a function of the skin; vitamin C is obtained through diet.

Choice A rationale: While dietary fiber is important for bowel health, raw vegetables can be harder to digest. Cooking or steaming vegetables may be a more suitable option for some individuals with constipation.
Choice B rationale: Limiting activity can contribute to constipation, as physical activity helps stimulate bowel movements.
Choice C rationale: Drinking four to five glasses of water daily is important for maintaining hydration and supporting normal bowel function. Dehydration can contribute to constipation.
Choice D rationale: Bearing down hard when defecating may increase the risk of complications and is not a recommended strategy for relieving constipation.

Choice A rationale: The absence of bowel sounds on post-operative day 2 may indicate paralytic ileus, which is a temporary impairment of bowel motility. Paralytic ileus can last for 3-5 days postoperatively and is considered a normal response to surgery.
Choice B rationale: It is not normal for all post-op patients to have absent bowel sounds on day 2. Bowel sounds should typically return within the first 24 hours after surgery.
Choice C rationale: The absence of bowel sounds can be a normal finding in the immediate postoperative period, especially within the first 24 hours. However, it becomes abnormal if prolonged.
Choice D rationale: Documenting absent bowel sounds is appropriate, but notifying the physician should be based on the overall clinical picture and other symptoms.

1 fluid ounce (fl oz) is approximately equal to 29.57 mL. 5 fl oz x 29.57= 147.85

=148 mL (rounded off to the nearest whole number)

Choice A rationale: Purulent drainage is thick and opaque, often indicating infection.
Choice B rationale: Serous drainage is thin and watery, typically clear or slightly yellow.
Choice C rationale: Sanguineous drainage is bright red and indicates fresh bleeding.
Choice D rationale: Serosanguineous drainage is thin and pale pink-yellow, representing a mixture of serous and sanguineous components.

Choice A rationale: Hemostasis is the initial phase of wound healing that involves vasoconstriction and clot formation to control bleeding.
Choice B rationale: The inflammatory phase involves the removal of debris and the influx of inflammatory cells to the wound site.
Choice C rationale: The maturation phase is characterized by the remodeling of collagen and scar formation.
Choice D rationale: Granulation tissue formation and easy bleeding during wound care are characteristic of the proliferation phase, which involves tissue repair and regeneration.