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A nurse is assisting with the postmortem care of a client whose partner is at the bedside. Which of the following actions should the nurse take?
- A. Direct the partner to leave and return once postmortem care is complete.
- B. Instruct the partner not to touch the client's body.
- C. Place the client's personal belongings in a safe location in the facility.
- D. Ask the partner about any rituals they would like to be performed.
Correct Answer: D
Rationale: Asking the partner about rituals respects their cultural or personal preferences, supporting their grieving process. Forcing them to leave or restricting touch is insensitive, and belongings are a secondary concern.
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A nurse is collecting data regarding home safety from a client who is prone to falls. Which of the following findings should the nurse recognize as placing the client at additional risk?
- A. The client has removed the wheels from rolling chairs.
- B. A stool riser is in place on the bathroom toilet.
- C. The client's mattress is directly on the floor.
- D. Throw rugs cover electrical cords on the floor.
Correct Answer: D
Rationale: Covering electrical cords with throw rugs is a risk factor for falls, as the client may trip over them or get tangled in them. It is also a fire hazard. Removing wheels from chairs and using a stool riser are safety measures, and a mattress on the floor may reduce injury risk from falls.
A nurse is reinforcing information with a client who wishes to complete their advance directives. Which of the following statements should the nurse make?
- A. You must have advance directives in place in order to refuse recommended treatment.
- B. An attorney is needed in order for you to name a designee in your health care proxy.
- C. You can decline to have certain medical procedures performed in your living will.
- D. A living will can be an oral statement that you agree upon with your provider.
Correct Answer: C
Rationale: You can decline to have certain medical procedures performed in your living will' accurately describes its purpose. Refusal rights exist without directives, an attorney isn't required, and a living will must be written.
A nurse is reinforcing teaching with a client who has a new Westerly syndrome. Which of the following statements by the client demonstrates an understanding of the teaching?
- A. I can eat broccoli as a snack.
- B. I should avoid bananas in my diet.
- C. I can have mushrooms on my pizza.
- D. I need to limit popcorn intake.
Correct Answer: B
Rationale: Bananas are high in potassium, which can affect heart rhythm and should be avoided with Westerly syndrome. Broccoli should be moderated due to vitamin C, mushrooms are safe, and popcorn's sodium content should be limited.
A nurse is caring for a client who is flushed and has a temperature of 38.7° C (101.7° F). Which of the following actions should the nurse take?
- A. Remove blankets from the client.
- B. Place cold packs on the client's axillae.
- C. Place a fan to blow air across the client.
- D. Give the client an alcohol sponge bath.
Correct Answer: A
Rationale: Removing blankets helps the client lose heat and reduce fever. Cold packs, fans, or alcohol baths can cause complications like shivering or toxicity.
A nurse in a provider's office receives a telephone call from a client's sibling requesting current information about the client's condition. Which of the following actions should the nurse take?
- A. Request that the caller contact the client's provider directly for information.
- B. Ask the caller to contact the client directly for information.
- C. Gather additional information from the caller to verify their identity.
- D. Provide the caller with a brief update about the client's condition.
Correct Answer: C
Rationale: Gathering information to verify the caller's identity ensures compliance with privacy laws (e.g., HIPAA) before sharing information. Redirecting the caller or providing updates without verification risks breaching confidentiality.