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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.
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A nurse is caring for a client who is receiving detoxification treatment for an opioid use disorder. As the nurse is preparing to administer a methadone IM injection, the client tells the nurse, 'I am afraid of needles.' Which of the following actions should the nurse take?
- A. Remind the client that they must receive the medication as prescribed.
- B. Tell the client not to worry because the pain will be temporary.
- C. Request a change in the medication route to PO.
- D. Ask one of the client's loved ones to encourage them to receive the IM medication.
Correct Answer: C
Rationale: Requesting a PO route addresses the client’s fear while ensuring treatment.
A nurse is assisting a client in selecting an appropriate diet. Which of the following statements should the nurse make?
- A. Choose foods high in fiber and low in fat.
- B. Include a variety of fruits and vegetables.
- C. Drink plenty of water throughout the day.
- D. Limit the intake of sugary and processed foods.
Correct Answer: A
Rationale: High-fiber, low-fat foods support digestion and heart health.
A nurse is collecting data from a client who has diabetes mellitus. The nurse should ask which of the following to determine the client's ability to provide foot self-hygiene?
- A. Do you have any problems taking care of your feet?
- B. Do you go barefoot at home?
- C. Have you noticed any problems with foot swelling?
- D. Have you had a problem with ingrown toenails?
Correct Answer: A
Rationale: This directly assesses ability to perform foot care, critical for diabetes management.
A nurse is reinforcing discharge teaching about fecal occult blood testing with a client. Which of the following instructions should the nurse include in the teaching?
- A. Place a thick layer of stool on the specimen card.
- B. Urinate prior to collecting the stool specimen.
- C. Discontinue supplements containing vitamin C 24 hours before the test.
- D. Refrain from consuming pork 7 days before the test.
Correct Answer: C
Rationale: Vitamin C can cause false negatives, so discontinuing it ensures accuracy.
A nurse is reinforcing teaching with an older adult client who has urinary incontinence. Which of the following instructions should the nurse include?
- A. Drink citrus juice with meals.
- B. Train the bladder by voiding every 5 hours.
- C. Apply adult diapers at bedtime.
- D. Perform pelvic-muscle exercises.
Correct Answer: D
Rationale: Pelvic-muscle exercises strengthen the pelvic floor, improving bladder control.