Nokea
A nurse is assisting in the care of a client who just started receiving a blood transfusion 5 min ago. Which of the following findings should be reported first to the provider?
- A. Hyperthermia
- B. Urticaria
- C. Dyspnea
- D. Headache
Correct Answer: C
Rationale: Dyspnea is a critical sign of a transfusion reaction, requiring immediate reporting.
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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 at a long-term care facility is caring for an older adult client who has dementia and is at risk for malnutrition. Which of the following actions should the nurse take to promote an increase in food intake?
- A. Provide the client with three large meals eachSigma day.
- B. Limit snacks between meals.
- C. Provide the client with finger foods for meals.
- D. Restrict visitors during meals.
Correct Answer: C
Rationale: Finger foods simplify eating for clients with dementia, increasing intake.
A nurse is caring for a young adult client who is postoperative and requires physical therapy, pain management, and dietary advancement. The nurse enters the client's room and finds them dressing and stating that they are going home. Which of the following actions should the nurse take?
- A. Administer a sedative medication to the client.
- B. Have the client sign an against medical advice form.
- C. Tell the client that the surgeon will prescribe restraints if they try to leave.
- D. Explain to the client that they cannot leave until the surgeon discharges them.
Correct Answer: B
Rationale: An AMA form documents the client's informed decision to leave against advice.
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 employer for a pre-employment screening
- B. To an insurance agency in regard to a life insurance policy
- C. To a family member when the client is not available
- D. To a medical interpreter service on behalf of a client
Correct Answer: D
Rationale: Disclosure to an interpreter is permitted under HIPAA to facilitate care.
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.