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A nurse is caring for a client who has a new colostomy. The client refuses to participate in her ostomy care, saying, 'I'm not touching that thing.' Which of the following actions should the nurse take?
- A. Ask the client to explain her feelings.
- B. Request that someone from the client's family participate in the care.
- C. Explain why her participation is important.
- D. Tell the client that it is safe to touch her ostomy.
Correct Answer: A
Rationale: Asking about feelings shows empathy and helps address the client’s concerns.
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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 administer medications to a client. Which of the following pieces of information should the nurse use as a client identifier?
- A. Photograph
- B. Medical diagnosis
- C. Age
- D. Room number
Correct Answer: A
Rationale: A photograph, combined with other identifiers like name and birthdate, ensures positive patient identification.
Findings that require immediate follow-up: deep tendon reflexes 4+, generalized weakness, mild leg cramping, heart rate irregular, bowel sounds hyperactive x 4 quadrants
- A. Deep tendon reflexes 4+
- B. Generalized weakness
- C. Mild leg cramping
- D. Heart rate irregular
- E. Bowel sounds hyperactive x 4 quadrants
Correct Answer: A,B,C,D,E
Rationale: A: Hyperreflexia suggests magnesium deficiency. B,C: Weakness and cramping indicate electrolyte issues. D: Irregular heart rate risks arrhythmia. E: Hyperactive bowels may relate to vomiting.
A nurse is preparing to reinforce teaching with a client who has expressive aphasia. Which of the following actions should the nurse plan to take?
- A. Provide the teaching without expecting the client to respond.
- B. Determine the client's ability to use a communication board
- C. Speak with a loud voice while providing the information.
- D. Avoid the use of facial gestures during the instructions.
Correct Answer: B
Rationale: A communication board aids clients with expressive aphasia in conveying needs, enhancing teaching effectiveness.
A nurse is caring for a client and observes a nurse from another unit reviewing the client's medical record. Which of the following actions should the nurse take?
- A. Tell the nurse that permission from the risk manager is required to view the client's record.
- B. Remind the nurse that only staff caring for the client may access the client's record.
- C. Complete an incident report about the breach of confidentiality.
- D. Contact facility security to remove the nurse from the unit.
Correct Answer: B
Rationale: Reminding about access rules upholds confidentiality standards.