250 FINAL

A client has been experiencing extreme fatigue lately. The nurse suspects anemia and examines the client to identify additional clinical manifestations to support this inference. Which locations are the clients body should the nurse assess? SAA 1. Sclera 2. Nail beds 3. Conjunctivae 4. Palms of hands 5. Bony prominences

2,3,4 2. Nail beds 3. Conjunctivae 4. Palms of hands

A nurse provides education to a client about how to prevent constipation. The nurse concludes that the teaching is understood when the client makes which statements? SAA 1. "I may eat potatoes at dinner daily." 2. "I should bring at least six glasses of water every day." 3. "I must eat eggs for breakfast three times a week." 4. "I can include bran muffins in my breakfast daily." 5. "I will walk every day as part of my exercise regiment."

2,4,5 2. "I should bring at least six glasses of water every day." 4. "I can include bran muffins in my breakfast daily." 5. "I will walk every day as part of my exercise regiment."

The laboratory report of a client reveals that the platelet count is 60,000/microliter. Which integumentary changes can be anticipated in this client? SAA 1. Cyanosis 2. Petechiae 3. Varicosity 4. Ecchymosis 5. Hematoma

2,4,5 2. Petechiae 4. Ecchymosis 5. Hematoma

A female client has a history of recurrent urinary track infections. What should the nurse include in the teaching plan when educating the client about the health practices that may help decrease future urinary tract infections? A. "Wear cotton underpants." B. "Void at least every 6 hours." C. "Increase foods containing alkaline ash in the diet." D. "Wipe from back to front after toileting."

A. "Wear cotton underpants."

After a client has a total gastrectomy, the nurse plans to include in the discharge teaching the need for what treatment? A. Monthly injections of cyanocobalamin B. Regular daily use of a stool softener C. Weekly injections of iron dextran D. Daily replacement therapy of pancreatic enzymes

A. Monthly injections of cyanocobalamin

Which term should the nurse use to describe bone loss greater that normal but less than that caused by osteoporosis? A. Osteopenia B. Osteomyelitis C. Osteomalacia D. Osteoarthritis

A. Osteopenia

The nurse understands that the BEST way to reduce catheter-associated urinary tract infections (CAUTIs) in long-term indwelling catheters is to do what? A. Perform catheter care twice a day. B. Replace the catheter on a routine basis C. Administer cranberry tablets three times each day D. Give antibiotics for the duration of catheter placement

A. Perform catheter care twice a day.

Which key feature does the nurse associate with a stage 2 pressure ulcer? A. Presence of non-intact skin B. Development of sinus tracts C. Damage to the subcutaneous tissues D. Appearance of a reddened area over a bony prominence

A. Presence of non-intact skin

Elbow restraints have been prescribed for a confused client to keep the client from pulling out a nasogastric tube and indwelling urinary retention catheter. What is MOST important for the nurse to do? A. Have the prescription renewed every 48 hours B. Assess the client's condition per hospital protocol. C. Provide range of motion to the client's elbows every shift D. Document output from the tube and catheter every two hours

B. Assess the client's condition per hospital protocol.

While assessing the skin of a light-skinned client, the nurse concludes that the client has ecchymosis. Which skin color variation would confirm this diagnosis? A. Gray color B. Dark red color C. Deep brown color D. White color

B. Dark red color

Healthcare provider prescribes dietary and medication therapy for a client with a diagnosis of gastroesophageal reflux disease (GERD). What is MOST appropriate for the nurse to teach the client about meal management? A. Snack daily in the evenings B. Divide food into four to six small meals a day C. Eat the last of three daily meals by 8:00pm D. Suck peppermint candy after each meal

B. Divide food into four to six small meals a day

The nurse is preparing an individualized teaching plan for a client with osteoarthritis. The nurse recognizes which abnormality specific to osteoarthritis? A. Ulnar drift B. Heberden nodes C. Swan-neck deformity D. Boutonniere deformity

B. Heberden nodes

A nurse is caring for a client who has urinary incontinence as the result of a cerebrovascular accident (brain attack). What action should the nurse include in the plan of care to limit the occurrence of urinary incontinence? A. Insert a urinary retention catheter B. Institute measures to prevent constipation C. Encourage an increase in the intake of caffeine D. Suggest that a carbonated beverage be ingested daily

B. Institute measures to prevent constipation

Client is admitted to the hospital after a motor vehicle accident with multiple abrasions and lacerations to the chest and all four extremities. The nurse helps the client select food items for the upcoming meals. Which food items will the nurse recommend? A. Meatloaf and tea B. Meatloaf and strawberries C. Chicken soup and baked apple D. Chicken soup and buttered bread

B. Meatloaf and strawberries

Which diagnostic study is used to determine a client's bone density? A. Diskogram B. Standard X-ray C. Computed tomography scan D. Magnetic resonance imaging

B. Standard X-ray

Upon assessment the nurse finds to following (See Image). The nurse will prepare the client for which type of surgery? A. Keratoplasty B. Trabeculoplasty C. Cataract removal D. Laser in situ keratomileusis (LASIK)

C. Cataract removal

Which ethnic group has a greater incidence of osteoporosis due to musculoskeletal differences? A. Irish Americans B. African Americans C. Chinese Americans D. Egyptian Americans

C. Chinese Americans

A client with glaucoma asks a nurse about future treatment and precautions. Which information should the nurse's explanation include? A. Avoidance of cholinergics B. Surgical replacement of lens C. Continuation of therapy for life D. Prevention of high blood pressure

C. Continuation of therapy for life

A nurse is assessing a client's eye and finds the following (see image). Which condition can be identified from the given figure? A. Strabismus B. Keratoconus C. Corneal ulcer D. Retinal detachment

C. Corneal ulcer

A nurse is assessing a client with a diagnosis of primary open-angle glaucoma. Which ocular symptom should the nurse expect the client to report? A. Attacks of acute pain B. Constant blurred vision C. Decreased peripheral vision D. Complete loss of central vision

C. Decreased peripheral vision

Following a motor vehicle accident a client reports seeing frequent flashes of light. Which condition should the nurse be prepared to address? A. Glaucoma B. Scleroderma C. Detached retina D. Cerebral concussion

C. Detached retina

A thin 24 year old woman who runs 10 miles each week asks the nurse for advice about preventing osteoporosis. Which vitamin and other dietary supplement should the nurse recommend? A. Vitamin E and ginseng tea B. Vitamin B and ginkgo biloba C. Vitamin D and calcium citrate D. Vitamin c and glucosamine/chondroitin

C. Vitamin D and calcium citrate

The nurse is reviewing the plan of care for a client who is scheduled for a barium swallow. What will the plan include? A. Giving clear fluids on the day of the test B. Asking the client about allergies to iodine C. Administering cleansing enemas before the test D. Administering a laxative after the procedure

D. Administering a laxative after the procedure

A nurse is teaching a client with a diagnosis of open-angle glaucoma. The nurse explains that the chief aim of treatment is to meet which goal? A. Rest the eye B. Dilate the pupil C. Prevent secondary infections D. Control the intraocular pressure

D. Control the intraocular pressure

After surgery to repair a retinal detachment, an older adult client is transferred to the post-anesthesia care unit with the affected eye patched. During the first four hours after surgery, the nurse should plan to notify the primary healthcare provider if the client reports which information? A. Has not voided B. Cannot open the eye C. Cannot remember the date D. Has sharp pain in the affected eye

D. Has sharp pain in the affected eye

An obese adult develops an abscess after abdominal surgery. The wound is healing by secondary intention and requires repacking and redressing every 4hrs. Which diet should the nurse expect the healthcare provider to prescribe to BEST meet this client's immediate nutritional needs? A. Low in fat and vitamin D B. High in calories and fiber C. Low in residue and bland D. High in protein and vitamin C

D. High in protein and vitamin C

The fire alarm is sounding in a skilled nursing facility and smoke is pouring from the kitchen. What should the nurse do to ensure the safety of the clients. staff, and family members? SAA 1. Move bedridden clients via stretcher 2. Place ambulatory clients in 3. Turn off all sources of supplemental oxygen 4. Provide manual respiratory support to critically ill clients 5. Close all windows and doors and use an ABC fire extinguisher

1, 3, 4, 5 1. Move bedridden clients via stretcher 3. Turn off all sources of supplemental oxygen 4. Provide manual respiratory support to critically ill clients 5. Close all windows and doors and use an ABC fire extinguisher

A nurse is completing the health history of a client admitted to the hospital with osteoarthritis. The nurse expects the client to report that which joints were involved initially? SAA 1. Hips 2. Joints 3. Ankles 4. Shoulders 5. Metacarpals

1,2 1. Hips 2. Joints

A client with GERD receives a prescription for an H2 receptor antagonist. Which medications are within the classification of an H2 receptor antagonist? SAA 1. Nizatidine 2. Ranitidine 3. Famotidine 4. Lansoprazole 5. Metoclopramide

1,2,3 1. Nizatidine 2. Ranitidine 3. Famotidine

The registered nurse is teaching a nursing student about interventions that reduce the risk of pressure ulcers in a client. Which statements made by nursing student indicate effective learning? SAA 1. "I will elevate the head of the client's bed to no more than 30 degrees." 2. "I will ensure that the client is turned and repositioned at least every two hours." 3. "I will advise the client to apply talc directly to the perineum." 4. "I will ensure that the client's fluid intake is 2000 to 3000 mL/ day 5. "I will teach the client to refrain from eating a high-protein and calorie diet

1,2,4 1. "I will elevate the head of the client's bed to no more than 30 degrees." 2. "I will ensure that the client is turned and repositioned at least every two hours." 4. "I will ensure that the client's fluid intake is 2000 to 3000 mL/ day

What should the nurse do to prevent deformities of the knee in a client with an exacerbation of arthritis? SAA 1. Encourage motion of the joint 2. Maintain a knee brace on the leg 3. Keep the client on a regimen of bed rest 4. Maintain joints in functional alignment when resting 5. Immobilize the joint with pillows until pain subsides

1,2,4 1. Encourage motion of the joint 2. Maintain a knee brace on the leg 4. Maintain joints in functional alignment when resting

A client with renal disorder is scheduled for an intravenous pyelogram (IVP). Which interventions should the nurse undertake prior to the procedure?SAA 1. Ensure that the consent form is signed 2. Assess the client for iodine sensitivity 3. Have the client remove all metal objects 4. Administer an enema or cathartic to the client 5. Instruct the client to lie still during the procedure

1,2,4 1. Ensure that the consent form is signed 2. Assess the client for iodine sensitivity 4. Administer an enema or cathartic to the client

A client is diagnosed with hyperthyroidism and is treated with 131 I. Before discharge the nurse teaches the client to observe for signs and symptoms of therapy-induced hypothyroidism. Which signs and symptoms should be included in the teaching? SAA 1. Fatigue 2. Dry skin 3. Insomnia 4. Intolerance to heat 5. Progressive weight gain

1,2,5 1. Fatigue 2. Dry skin 5. Progressive weight gain

Registered nurse is teaching a client regarding preventative measures for genital tract infections. Which statement made by the client indicates the need for further education? SAA 1. "I should take frequent bubble baths." 2. "I should decrease the use of dietary sugar." 3. "I should choose hosiery with nylon crotch." 4. "I should use colored and scented toilet tissues." 5. "I should limit the time spent in damp exercise clothes."

1,3,4 1. "I should take frequent bubble baths." 3. "I should choose hosiery with nylon crotch." 4. "I should use colored and scented toilet tissues."

A nurse is providing discharge instructions for a client with a diagnosis of gastroesophageal reflux disease (GERD). What should the nurse advise the client to do to limit symptoms of GERD? SAA 1. Avoid heavy lifting 2. Lie down after eating 3. Avoid drinking alcohol 4. Eat small, frequent meals 5. Increase fluid intake with meals 6. Wear an abdominal binder or girdle

1,3,4 1. Avoid heavy lifting 3. Avoid drinking alcohol 4. Eat small, frequent meals

A nurse is providing education about excellent food sources of vitamin A for a client who is deficient in this vitamin. Which foods should the nurse include in the teaching? SAA 1. Carrots 2. Oranges 3. Tomatoes 4. Green leafy greens 5. Yellow/orange vegetables

1,4,5 1. Carrots 4. Green leafy greens 5. Yellow/orange vegetables

The nurse in a campus health clinic is assessing female students for risk factors associated with the future development of osteoporosis. What factors are included in this assessment? SAA 1. Cigarette smoking 2. Moderate exercise 3. Use of street drugs 4. Familial predisposition 5. Inadequate intake of dietary calcium

1,4,5 1. Cigarette smoking 4. Familial predisposition 5. Inadequate intake of dietary calcium

A client is admitted with thrombocytopenia. Which specific nursing actions are appropriate to include in the plan of care for this client? SAA 1. Avoid intramuscular injections 2. Institute neutropenic precautions 3. Monitor the white blood cell count 4. Administer prescribed anticoagulants 5. Examine the skin for ecchymotic areas

1,5 1. Avoid intramuscular injections 5. Examine the skin for ecchymotic areas

A nurse is preparing to administer an ophthalmic medication to a client. What techniques should the nurse use for this procedure? SAA 1. Clean the eyelid and eyelashes enter 2. Place the dropper against the eyelid 3. Apply clean gloves before beginning the procedure 4. Instill the solution directly onto the cornea 5. Press on the nasolacrimal duct after instilling the solution

1.3.5 1. Clean the eyelid and eyelashes enter 3. Apply clean gloves before beginning the procedure 5. Press on the nasolacrimal duct after instilling the solution

A nurse provides dietary instruction to a client who has iron deficiency anemia. Which food choices by the client does the nurse consider MOST desirables? SAA 1. Raw carrots 2. Boiled Spinach 3. Dried apricots 4. Brussels sprouts 5. Asparagus spears

2. Boiled spinach 3. Dried apricots

A client comes for an annual physical examination. To provide appropriate nutritional counseling, the nurse calculates the client's BMI. The Client's weight is 65kg, and the height is 1.7 meters. What is the client's BMI?

22.5 BMI BMI= weight in kg /height in meters squared 1.7m x 1.7m= 2.89 65 kg/2.89= 22.5

Which nursing interventions are beneficial in the event of fire in the hospital? SAA 1. Opening the doors and windows 2. Moving ambulatory clients in wheelchairs to a safe location 3. Putting out the fire first and then removing the clients from fire area 4. Asking ambulatory clients to help push wheelchair clients out of danger 5. Maintaining injured clients' respiratory status manually until removed from the fire area

4,5 4. Asking ambulatory clients to help push wheelchair clients out of danger 5. Maintaining injured clients' respiratory status manually until removed from the fire area

A client is being prepared for discharge from an ambulatory surgical clinic after a cataract extraction and an intraocular lens implant. Which statement indicates to the nurse that the discharge teaching is effective? A. "I should call the clinic if my eye begins to hurt." B. "I am so glad that I can take a shower tomorrow." C. "There will be bright flashes of light for a few days." D. "My vision should show some improvement by tomorrow."

A. "I should call the clinic if my eye begins to hurt."

Which client statement indicates to the nurse that a client who is receiving cyanocobalamin (vitamin B12) therapy for an intrinsic factor deficiency understands the treatment? A. "I should have a vitamin b12 injection every month? B. "I'll take my B12 vitamin every morning with my breakfast C. "I'll have a salad every day because vitamin B12 is in green vegetables." D. "I should feel better because my vitamin B12 treatments will improve my aplastic anemia

A. "I should have a vitamin b12 injection every month?

I registered nurse is teaching a student nurse about the role of nurses in case of a fire in the hospital. Which statement made by the student nurse indicates an effective learning? A. "I will continue oxygen for all clients, even those who can breathe without it." B. "I will seek to put out the fire by closing doors and windows and use an ABC extinguisher." C. "I will manually maintain the respiratory status for clients on life support until they are removed from the fire area." D. "I will take the help of staff members to move bedridden clients on blankets or carry them from the fire area."

A. "I will continue oxygen for all clients, even those who can breathe without it."

A client asks for information about glaucoma. How should the nurse explain glaucoma to the client? A. An increase in the pressure within the eyeball B. An opacity of the crystalline lens or its capsule C. A curvature of the cornea that becomes unequal D. A separation of the neural retina from the pigmented retina

A. An increase in the pressure within the eyeball

A client with GERD is being treated with dietary management. The client states, "I like to have a glass of juice every day." Which juice will the nurse recommend? A. Apple B. Orange C. Tomato D. Grapefruit

A. Apple

A client with localized redness and swelling due to a bee sting reports intense local pain, a burning sensation, and itching. What would be the MOST appropriate nursing action? A. Applying cold compress to the affected area B. Ensuring the client keeps the skin clean and dry C. Monitoring for neurological and cardiac symptoms D. Advising the client to launder all clothes with bleach

A. Applying cold compress to the affected area

Which beta-adrenergic blocker is prescribed to clients with glaucoma? A. Betaxolol B. Carbachol C. Brimonidine D. Methazolamide

A. Betaxolol

Which drug is derived from a natural source and may be prescribed for the treatment of osteoporosis? A. Calcitonin B. Raloxifene C. Clomiphene D. Bisphosphonates

A. Calcitonin

Which client responses does the nurse determine represent the HIGHEST risk for the development of pressure ulcers? A. Incontinence and inability to move independently B. Periodic diaphoresis and occasional sliding down in bed C. Reaction to just painful stimuli and receiving tube feedings D. Adequate nutritional intake and spending extensive time in a wheelchair

A. Incontinence and inability to move independently

A nurse is assessing a client with a diagnosis of dry age-related macular degeneration. Which ocular symptom should the nurse expect the client to report? A. Loss of central vision B. Attacks of acute pain C. Constant blurred vision D. Decreased peripheral vision

A. Loss of central vision

A client who takes daily megadoses of vitamins is hospitalized with joint pain, loss of hair, yellow pigmentation of the skin, and an enlarged liver due to vitamin toxicity. What type of toxicity does the nurse suspect> A. Retinol (vitamin A) B. Thiamine (vitamin B1) C. Pyridoxine (vitamin B6) D. Absorbic acid (vitamin C)

A. Retinol (vitamin A)

Which client is MOST at risk for osteoporosis? A. A nonsmoking 60 year old woman, 5ft 7in (170cm) tall and 173 lb (78.5kg) B. A 66 year old white woman, 5ft 1in (155cm) tall and 100 lb (45kg), who is a paralegal C. a 68 year old woman, 5ft 5in (165cm) tall and 140 lb (63.5 kg), who is a retired receptionist D. A 63 year old woman, 5ft 4in (163 cm) and 135 lb (61kg), who takes calcium carbonate daily

B. A 66 year old white woman, 5ft 1in (155cm) tall and 100 lb (45kg), who is a paralegal

Which site is best for the nurse to obtain a urinalysis specimen for a critical care client with an indwelling urine catheter? A. Tubing luer-lok port B. Distal end of the tubing C. Urinary drainage bag D. Catheter insertion site

A. Tubing luer-lok port

What instruction regarding sample collection should the nurse give a client who is ordered a clean-catch urine specimen? A. Urinate small amount, stop flow, fill half a cup B. Collect the las urine sample voided in the night C. Keep the urine sample in dry warm area if delay is anticipated D. Send the urine sample to the laboratory within 6 hours of collection

A. Urinate small amount, stop flow, fill half a cup

A pregnant client with iron-deficiency anemia is prescribed iron supplements daily. To help the client increase iron absorption, the nurse should suggest that the client eat foods high in which substance? A. Vitamin C B. Fat content C. Water content D. Vitamin B complex

A. Vitamin C

A complete blood count (CBC), urinalysis, and X-ray examination of the chest are prescribed for a client before surgery. The client asks why these tests are done. Which is the BEST reply by the nurse? A. "Don't worry; theses tests are routine." B. " They are done to identify other health risks." C. "They determine whether surgery will be safe." D. " I don't know; your healthcare provider prescribed them."

B. " They are done to identify other health risks."

Which information from the client's history does the nurse identify as a risk factor for developing osteoporosis? A. Takes estrogen therapy B. Receives long-term steroid therapy C. Has a history of hypoparathyroidism D. Engages in strenuous physical activity

B. Receives long-term steroid therapy

A client reports smoke coming from a utility room on the nursing unit. What is the initial action the nurse should take? A. Pull the fire alarm on the unit B. Remove anyone who is in immediate danger C. Obtain a fire extinguisher and report the fire area D. Close all windows and fire doors and await further instructions

B. Remove anyone who is in immediate danger

A client with hyperthyroidism asks the nurse about the tests that will be prescribed. Which diagnostic tests should the nurse include in a discussion with this client? A. Thyroxine (T4) and X-ray films B. Thyroid-stimulating hormone (TSH) assay and triiodothyronine (T3) C. Thyroglobulin level and PO2 D. Protein-bound iodine and sequential multichannel auto analyzer (SMA)

B. Thyroid-stimulating hormone (TSH) assay and triiodothyronine (T3)

A nurse is caring for a client who reports urinary problems, and the healthcare provider prescribes a cholinergic medication. Which urinary problem will this medication correct? A. Urinary frequency due to bladder spasticity B. Urinary retention due to bladder atony C. Pain due to urinary tract calculi D. Urinary urgency due to urinary tract infections

B. Urinary retention due to bladder atony

A 60 year old client with gastric cancer has a shiny tongue, paresthesias of the limbs, and ataxia. The laboratory results show cobalamin levels of 125 pg/mL. Which medication would the nurse consider to be a high priority for the client? A. Oral hydroxyurea B. Vitamin B12 injections C. Oral iron supplements D. Erythropoietin injections

B. Vitamin B12 injections

The nurse is preparing to initiate intravenous antibiotic therapy for a client who developed an infection along the incision after having a total knee replacement. Before starting the first dose of intervenous antibiotics, which task should the nurse ensure has been completed? A. Red blood cell count B. Wound culture C. Knee x-ray D. Urinalysis

B. Wound culture

A registered nurse is teaching a nursing student about how to safely use a urinary catheter. Which statement made by the nursing student indicates ineffective learning? A. "I will avoid the pooling of urine in the tubing." B. "I will avoid prolonged clamping of the tubing." C. "I will avoid draining urine from the tubing before ambulation." D. "I will avoid raising the drainage tube above the level of the bladder."

C. "I will avoid draining urine from the tubing before ambulation."

A client who has repeated episodes of cystitis is scheduled for a cystoscopy to determine the possibility of urinary tract abnormalities. The client asked the nurse to describe the procedure. Which is the nurse is MOST appropriate response? A. "It is a computerized scan that outlines the bladder and surrounding tissue." B. "It is an x-ray film of the abdomen, kidneys, ureters, and bladder after administration of dye." C. "It is the visualization of the inside of the bladder with an instrument connected to a source of light." D. "It is the visualization of the urinary tract through urethral catheterization and the use of radiopaque material."

C. "It is the visualization of the inside of the bladder with an instrument connected to a source of light."

A client diagnosed with GERD is being treated with antacid therapy. When teaching the client about the therapy, what does the nurse reinforce? A. Antacids should be taken 1 hour before meals B. These should be scheduled at 4-hour intervals C. Antacid tablets are just as fast and effective as the liquid form D. Antacids commonly interfere with the absorption of other drugs

D. Antacids commonly interfere with the absorption of other drugs

An older client with macular degeneration comes to the eye clinic. Which response reported by the client does the nurse identify as consistent with the diagnosis? A. Sees best in dim light B. Sees halos around lights C. Cannot see objects in the periphery D. Cannot see objects in the center of the visual field

D. Cannot see objects in the center of the visual field

Which nursing intervention is indicated for aging clients with decreased bone density? A. Teaching the client isometric exercises B. Advising the client to take a moist heat shower C. Providing supportive armchairs to the client D. Demonstrating weight-bearing exercises to the client

D. Demonstrating weight-bearing exercises to the client

A residual urine test is prescribed for a client with benign prostatic hyperplasia. What should the nurse instruct the client to do? A. Void after a urinary catheter is removed B. Collect a specimen of urine during midstream C. Attempt to void when a urinary catheter is in place D. Empty the bladder before a urinary catheter is inserted

D. Empty the bladder before a urinary catheter is inserted

Which clinical indicator is the nurse MOST likely to identify when exploring the history of a client with open-angle glaucoma? A. Constant blurring B. Abrupt attacks of acute pain C. Sudden, complete loss of vision D. Impairment of peripheral vision

D. Impairment of peripheral vision

The nurse is caring for a surgical client who develops a wound infection during hospitalization. How is this type of infection classified? A. Primary B. Secondary C. Superinfection D. Nosocomial

D. Nosocomial

A nurse is caring for an elderly client who has constipation. Which independent nursing intervention helps to reestablish a normal bowel pattern? A. Administer a mineral oil enema B. Offer 1 cup of fluid every hour C. Manually remove fecal impactions D. Offer a cup of prune juice

D. Offer a cup of prune juice

Client is being discharged from the hospital with an indwelling urinary catheter. The client asked about the best way to prevent infection and keep the catheter clean. Which would be appropriate for the nurse to include in the client teaching? A. Once a day, clean the tubing with mild soap and water, starting at the drainage bag and moving toward the insertion site . B. After cleaning the catheter site, it is important to keep the foreskin pushed back for 30 minutes to ensure adequate drying. C. Clean the insertion side daily using a solution of one part vinegar to two parts water D. Replace the drainage bag with a new bag once a week

D. Replace the drainage bag with a new bag once a week

A client has a pressure ulcer that is full thickness with the crosses into the subcutaneous tissue down to the underlying patient. The nurse should document the assessment finding as which stage of pressure ulcer? A. Stage I B. Stage II C. Stage III D. Unstageable

D. Unstageable