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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 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 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 preparing to instill an otic medication for an adult client. Which of the following actions should the nurse take?
- A. Request the client remain supine for 10 min following administration.
- B. Pull the client's pinna downward and back.
- C. Hold the ear dropper 1 cm (0.5 in) from the client's ear.
- D. Cleanse the client's outer ear with isopropyl alcohol to remove wax.
Correct Answer: C
Rationale: Holding the dropper 1 cm from the ear ensures precise administration without contamination.
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 at a long-term care facility is caring for an older adult client who has dementia and is at risk for malnutrition. Which of the following actions should the nurse take to promote an increase in food intake?
- A. Provide the client with finger foods for meals.
- B. Restrict visitors during meals.
- C. Limit snacks between meals.
- D. Provide the client with three large meals each day.
Correct Answer: A
Rationale: Finger foods enhance self-feeding and intake in dementia clients.