Nokea
The client has a new diagnosis of diabetes mellitus and is refusing to learn how to self-administer insulin.
A nurse is caring for a client who has a new diagnosis of diabetes mellitus and is refusing to learn how to self-administer insulin. Which of the following responses should the nurse make?
- A. You will suffer serious health issues if you don't take your medication.
- B. Have you considered how your decision to refuse medication will affect your family?
- C. I'd like to hear your thoughts about giving yourself this medication.
- D. Why don't you want to learn how to give yourself your medication?
Correct Answer: C
Rationale: Exploring the client's thoughts promotes understanding and respects autonomy.
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A nurse is receiving a telephone prescription from a client's provider. Which of the following actions should the nurse take? (Select all that apply)
- A. Instruct another nurse to record the prescription in the medical record.
- B. Ask the provider to spell out the name of the medication.
- C. Withhold the medication until the provider signs the prescription.
- D. Record the date and time of the telephone prescription.
- E. Request that the provider confirm the read-back of the prescription.
Correct Answer: B,D,E
Rationale: Spelling the medication, recording date/time, and confirming read-back ensure accuracy and safety.
A nurse is providing care to a client who is preparing to undergo surgery. The client inquires about advance directives. Which of the following statements should the nurse make?
- A. Advance directives are the same as a consent form for health care treatment.
- B. Advance directives protect your right to make your own health care decisions.
- C. Advance directives must be approved by your lawyer.
- D. Advance directives are for clients who have life-threatening conditions.
Correct Answer: B
Rationale: Advance directives ensure client autonomy in health care decisions.
A nurse is assisting with the care of a group of clients during a mass casualty event. Which of the following tasks should the nurse assign to an assistive personnel (AP)?
- A. Respond to family members about a client's condition.
- B. Determine which clients should be seen first.
- C. Clean and dress client abdominal wounds.
- D. Take vital signs on clients as they are admitted.
Correct Answer: D
Rationale: Taking vital signs is within the AP's scope, unlike triage or wound care.
A nurse is reinforcing teaching with a client about the use of budesonide for asthma management. Which of the following statements by the adolescent indicates an understanding of the teaching?
- A. I should use my inhaler when I have an asthma attack.
- B. I will rinse my mouth and gargle with water after each inhaler treatment.
- C. I will take my inhaler treatment before each meal and at bedtime.
- D. I should use my inhaler before exercising.
Correct Answer: B
Rationale: Rinsing the mouth after budesonide (a corticosteroid) prevents oral thrush, indicating understanding.
A nurse is assisting with preparing a client who is to have a central venous catheter inserted for the administration of total parenteral nutrition (TPN). Which of the following actions should the nurse take?
- A. Place the client in Sims' position for catheter insertion.
- B. Verify the amount of TPN solution the client is receiving every 4 hr.
- C. Use clean technique when changing the catheter dressing.
- D. Prepare the client for a chest x-ray to verify catheter placement.
Correct Answer: D
Rationale: A chest x-ray confirms correct catheter placement for TPN administration.