Nokea
A nurse in a provider's office is reviewing data from a client's medical record. Which of the following findings should the nurse identify as a risk factor for cardiovascular disease?
- A. Orthostatic hypotension
- B. Type 1 diabetes mellitus
- C. Family history of osteoporosis
- D. BMI of 24
Correct Answer: B
Rationale: Type 1 diabetes increases cardiovascular risk due to chronic hyperglycemia damaging blood vessels.
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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 preparing to set up a sterile field to change a sterile dressing on a client's abdominal wound. Identify the sequence of steps the nurse should take.
- A. Grasp the outermost flap of the sterile kit while opening away from the body.
- B. Open the innermost lower flap of the sterile kit while standing away from the sterile field.
- C. Open each side flap of the sterile kit individually while pulling to the side.
- D. Prepare a dry work surface above the waist level.
- E. Open the outside cover of the sterile kit and remove the dust cover.
Correct Answer: D,E,A,C,B
Rationale: D: Set up surface. E: Remove cover. A: Open outermost flap. C: Open side flaps. B: Open innermost flap maintains sterility.
A nurse is reinforcing teaching with a client about the use of a quad cane. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should wear shoes with smooth soles to help slide my weak leg forward.
- B. I should move my stronger leg forward before moving my weaker leg.
- C. I will move the cane forward 18 inches.
- D. I will hold the cane on my stronger side.
Correct Answer: B
Rationale: Moving the stronger leg first is correct for safe ambulation with a quad cane.
A nurse is observing an assistive personnel (AP) provide postmortem care for a client prior to visitation by their loved ones. Which of the following actions by the AP requires intervention by the nurse?
- A. Gathering the client's personal belongings
- B. Closing the client's eyes
- C. Washing the client's face
- D. Removing the client's dentures from their mouth
Correct Answer: D
Rationale: Dentures should remain in place to maintain facial structure for family visitation.
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 a medical interpreter service on behalf of a client
- B. To a family member when the client is not available
- C. To an employer for a pre-employment screening
- D. To an insurance agency in regard to a life insurance policy
Correct Answer: A
Rationale: Disclosure to an interpreter is permissible under HIPAA to facilitate care.