Nokea
A nurse is caring for a client who is postpartum. Which of the following documentations should the nurse include in the client's health record?
- A. Client instructed on self-care needs.
- B. Episiotomy approximated. 3 cm (1.18 in) in length.
- C. Client drank adequate amounts of fluid with meals.
- D. Oral temperature elevated at 0800.
Correct Answer: B
Rationale: Documenting the status of the episiotomy provides essential information regarding healing and recovery, a priority in postpartum care.
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A nurse is caring for a client who has a new prescription for a belt restraint. Which of the following actions should the nurse take?
- A. Apply the belt restraint over the client's gown.
- B. Tie the belt restraint to the side rail of the bed.
- C. Check the client's skin integrity every 4 hr.
- D. Make sure four fingers fit between the restraint and the client's body.
Correct Answer: A
Rationale: Applying the restraint over the gown protects skin and ensures comfort.
A nurse is coordinating care of a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?
- A. Measure the intake and output of a client who has received furosemide.
- B. Assess the pain level of a client who has received acetaminophen.
- C. Reinforce teaching with a client about crutch-gait walking.
- D. Check a client's peripheral IV site for redness or swelling.
Correct Answer: A
Rationale: Measuring intake and output is within the AP’s scope and appropriate for delegation.
A nurse is reinforcing teaching with a client about advance directives. Which of the following client statements indicates an understanding of the teaching?
- A. A family member will need to witness my signature on my living will.
- B. I need to create advance directives so that I can donate my organs.
- C. I can name my sibling as my designee in my durable power of attorney for health care.
- D. My advance directives can be enforced once my attorney approves them.
Correct Answer: C
Rationale: Naming a sibling as a designee in a durable power of attorney reflects understanding of advance directives.
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. Your quality of life will be compromised if you make this decision.
- B. How will you discuss this decision with your loved ones?
- C. Don't worry. Everything will work out for you.
- D. We should talk about your decision later.
Correct Answer: B
Rationale: Encouraging discussion with loved ones shows empathy and supports the client's autonomy.
A nurse is reinforcing teaching about dietary needs with the child of a client. They state, 'I don't know what to do because they're not eating.' Which of the following responses should the nurse make?
- A. Tell me more about what happens at mealtime.
- B. Why do you think they're not eating?
- C. I'm sure it's nothing serious and their appetite will return soon.
- D. They may need a feeding tube.
Correct Answer: A
Rationale: Exploring mealtime details provides insight into the client’s eating issues.