Nokea
A nurse in a long-term care facility is preparing to administer medications to a client who has advanced dementia and does not have an identification band. Which of the following actions should the nurse take to verify the client's identity?
- A. Ask the client to state their room number.
- B. Have the client state their phone number.
- C. Review the client's photograph in the medical record.
- D. Request an assistive personnel to identify the client.
Correct Answer: C
Rationale: A photograph in the record is a reliable identifier for a client with dementia.
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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. Don't worry. Everything will work out for you.
- B. Your quality of life will be compromised if you make this decision.
- C. We should talk about your decision later.
- D. How will you discuss this decision with your loved ones?
Correct Answer: D
Rationale: This response supports the client's autonomy and encourages communication.
A nurse is reinforcing teaching with a group of newly licensed nurses regarding client confidentiality. In which of the following situations can the nurse disclose health information without the client's written consent?
- A. To an insurance agency in regard to a life insurance policy
- B. To a family member when the client is not available
- C. To a medical interpreter service on behalf of a client
- D. To an employer for a pre-employment screening
Correct Answer: C
Rationale: Disclosure to an interpreter is allowed to facilitate care, adhering to HIPAA exceptions.
A nurse is reinforcing discharge teaching with a male client who has an indwelling urinary catheter. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will clamp the tube when I go for a walk.
- B. I will keep the drainage bag below the level of my waist.
- C. I will empty my drainage bag once a day.
- D. I will apply antiseptic ointment to the tip of my penis.
Correct Answer: B
Rationale: Keeping the bag below the waist prevents urine backflow and infection.
A nurse is assisting in the care of a client who is receiving newly prescribed IV antibiotics. Which of the following findings should the nurse report immediately?
- A. Small, raised vesicles over the body
- B. Rhinitis
- C. Itching of the skin
- D. Severe wheezing
Correct Answer: D
Rationale: Severe wheezing indicates a possible anaphylactic reaction, requiring immediate reporting.
A nurse is reinforcing a teaching plan regarding proper lifting with a client. Which of the following strategies should the nurse include to prevent back injury when lifting an object?
- A. Hold object away from the body.
- B. Tighten the abdominal muscles.
- C. Bend at the waist.
- D. Keep legs straight.
Correct Answer: B
Rationale: Tightening abdominal muscles stabilizes the spine during lifting.