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A nurse is assisting in the transfer of a client who has left-sided weakness from a bed to a chair. Which of the following actions should the nurse take?
- A. Stand on the client's stronger side when moving the client into the chair.
- B. Flex hips and knees when assisting the client to a standing position.
- C. Raise the bed to waist level before moving the client.
- D. Pivot on the foot farthest from the bed when assisting the client into the chair.
Correct Answer: B
Rationale: Flexing hips and knees uses proper body mechanics, aiding safe transfer.
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A nurse is assigning a semiprivate room to a client who has herpes zoster. Which of the following roommates is appropriate?
- A. A client who has rubella
- B. A client who has had varicella
- C. A client who is HIV-positive
- D. A client who has tuberculosis
Correct Answer: B
Rationale: A client with prior varicella is immune to herpes zoster, reducing transmission risk.
A nurse is caring for an older adult client who has a hearing aid. Which of the following actions should the nurse take when the client reports hearing a whistling sound from the hearing aid?
- A. Soak the hearing aid in warm water.
- B. Decrease the volume on the hearing aid.
- C. Clean the hearing aid with isopropyl alcohol.
- D. Turn the hearing aid off for 5 min.
Correct Answer: B
Rationale: Whistling (feedback) often indicates high volume; decreasing it resolves the issue.
A nurse is caring for a client who is postoperative and is preparing to walk for the first time in several days. Which of the following instructions should the nurse give the client to prevent orthostatic hypotension?
- A. Use your incentive spirometer.
- B. Dangle your legs over the side of the bed.
- C. Increase your intake of protein.
- D. Perform regular isometric exercises.
Correct Answer: B
Rationale: Dangling legs helps acclimate the body to positional changes, reducing hypotension risk.
A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? (Select all that apply.)
- A. A client reports being dissatisfied with the temperature of the meals provided.
- B. A client receives burns from a heating pad.
- C. A client becomes disoriented and falls out of bed.
- D. A client is unable to afford the physical therapy that the provider recommends.
- E. A client's visitor becomes dizzy and faints in the client's room.
Correct Answer: B,C,E
Rationale: B: Burns indicate harm. C: Falls require reporting. E: Visitor fainting is an unexpected event.
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.