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. Oral temperature elevated at 0800.
- B. Episiotomy approximated, 3 cm (1.18 in) in length.
- C. Client instructed on self-care needs.
- D. Client drank adequate amounts of fluid with meals.
Correct Answer: B
Rationale: Specific documentation like episiotomy status provides measurable, objective data.
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A nurse is collecting data from a client who has a BMI of 29. The nurse should document that the client is in which of the following weight categories?
- A. Obese
- B. Underweight
- C. Ideal body weight
- D. Overweight
Correct Answer: D
Rationale: A BMI of 25-29.9 is classified as overweight; 30+ is obese.
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. Request that someone from the client's family participate in the care.
- B. Ask the client to explain her feelings.
- C. Explain why her participation is important.
- D. Tell the client that it is safe to touch her ostomy.
- E. Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin.
Correct Answer: B
Rationale: Exploring feelings addresses emotional barriers, promoting eventual acceptance of care.
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 insurance agency in regard to a life insurance policy
- B. To an employer for a pre-employment screening
- C. To a medical interpreter service on behalf of a client
- D. To a family member when the client is not available
Correct Answer: C
Rationale: Disclosure to an interpreter is allowed under HIPAA to facilitate care, unlike the other scenarios.
A nurse is preparing to administer ampicillin to a school-age child who weighs 55 lb. The provider prescribes 50 mg/kg/day in 4 equal doses. Available is ampicillin oral suspension 125 mg/5 mL. How many mL should the nurse administer with each dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 5
Rationale: 55 lb = 25 kg; 50 mg/kg/day = 1250 mg/day; 1250 mg / 4 doses = 312.5 mg/dose; 312.5 mg ÷ 125 mg/5 mL = 12.5 mL/day; 12.5 ÷ 4 = 3.125 mL, rounded to 5 mL.
A nurse is reviewing the laboratory results for a client who reports vomiting and diarrhea for 2 days. Which of the following laboratory findings should the nurse expect?
- A. Hypocalcemia
- B. Hypermagnesemia
- C. Hyponatremia
- D. Hyperkalemia
Correct Answer: C
Rationale: Hyponatremia occurs from fluid and sodium loss in vomiting and diarrhea.