Nokea
A charge nurse on a long-term care unit is working with an assistive personnel who states, 'I am tired of all the changes on this unit. If things don't improve soon, I'm requesting a transfer.' Which of the following responses should the charge nurse make?
- A. Why don't you just file a formal complaint with Human Resources?
- B. So, you are upset about all of the recent changes on the unit?
- C. There has been too much complaining about these changes.
- D. Please, try to wait a little longer. Things will get better soon.
Correct Answer: B
Rationale: Reflective listening acknowledges the AP’s feelings and encourages discussion.
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A nurse is caring for a client who refuses their morning dose of antihypertensive medication. The client tells the nurse, 'I'm not going to take this medication because it makes me sick and dizzy.' Which of the following actions should the nurse take first?
- A. Document the refusal in the client's medical record.
- B. Return the medication to the medication cabinet.
- C. Inform the client of the potential consequences of their refusal.
- D. Notify the provider of the client's refusal.
Correct Answer: C
Rationale: Informing about consequences first respects autonomy and may encourage compliance.
A nurse is caring for a client who has a new colostomy. The client refuses to participate in her ostomy care, saying, 'I'm not touching that thing.' Which of the following actions should the nurse take?
- A. Ask the client to explain her feelings.
- B. Request that someone from the client's family participate in the care.
- C. Explain why her participation is important.
- D. Tell the client that it is safe to touch her ostomy.
Correct Answer: A
Rationale: Asking about feelings shows empathy and helps address the client’s concerns.
A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse plan to take?
- A. Use a 10-mL syringe filled with cleansing solution.
- B. Hold the syringe tip 2.5 cm (1 in) above the upper end of the wound.
- C. Cleanse the wound with cotton balls.
- D. Dry the wound bed with gauze squares.
Correct Answer: B
Rationale: Holding the syringe 2.5 cm above ensures effective irrigation without contamination.
A nurse is reinforcing teaching with a client who has an ostomy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will clean around the stoma with a moisturizing soap.
- B. I will press on the skin barrier for 30 seconds to ensure that it adheres.
- C. I will cut an opening in the skin barrier that is 1â„2 inch larger than the stoma.
- D. I will apply a thin layer of talc powder around the stoma before placing the appliance.
Correct Answer: B
Rationale: Pressing the skin barrier for 30 seconds ensures adhesion, preventing leakage.
A nurse is caring for a client who is confused and has a prescription for wrist restraints. Which of the following actions should the nurse take?
- A. Request a prescription renewal from the provider every 36 hr.
- B. Make sure two fingers fit under the restraints.
- C. Check the client's range of motion every 6 hr.
- D. Secure the restraints with a square knot.
Correct Answer: B
Rationale: Two fingers ensure the restraints are secure but not too tight.