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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. There has been too much complaining about these changes.
- B. So you are upset about all of the recent changes on the unit?
- C. Why don't you just file a formal complaint with Human Resources?
- D. Please, try to wait a little longer. Things will get better soon.
Correct Answer: B
Rationale: Acknowledging feelings fosters discussion and support, addressing the AP’s concerns.
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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. Notify the provider of the client's refusal.
- B. Document the refusal in the client's medical record.
- C. Inform the client of the potential consequences of their refusal.
- D. Return the medication to the medication cabinet.
Correct Answer: C
Rationale: Informing about consequences first educates the client, supporting informed decision-making.
A nurse is inserting an indwelling urinary catheter for a male client. After inserting the catheter 15 cm (6 in), the nurse feels resistance and no urine flows through the catheter. Which of the following actions should the nurse take?
- A. Inflate the catheter's balloon.
- B. Lower the penis to a 45° angle.
- C. Apply lidocaine gel to the urethra.
- D. Twist the catheter gently.
Correct Answer: D
Rationale: Gentle twisting can navigate urethral obstructions safely without causing trauma.
A nurse is collecting data from a client who is immobile and has a potential deep-vein thrombosis. Which of the following findings should the nurse report to the provider?
- A. Clammy skin
- B. Tortuous veins
- C. Bradycardia
- D. Calf swelling
Correct Answer: D
Rationale: Calf swelling is a key sign of DVT, indicating possible venous obstruction needing urgent evaluation.
A nurse is assisting with the care of a client who has cancer that has metastasized. The client has decided to discontinue chemotherapy treatment. Which of the following responses should the nurse make?
- A. How will you discuss this decision with your loved ones?
- B. Your quality of life will be compromised if you make this decision.
- C. We should talk about your decision later.
- D. Don't worry. Everything will work out for you.
Correct Answer: A
Rationale: This response supports the client’s autonomy and facilitates discussion about their decision.
A nurse is reinforcing teaching about beginning an exercise program with an older adult client who is at risk for osteoporosis. Which of the following activities should the nurse recommend?
- A. Bowling
- B. Walking
- C. Passive range-of-motion exercise
- D. Jogging
Correct Answer: B
Rationale: Walking, a weight-bearing exercise, strengthens bones, reducing osteoporosis risk safely.