Nokea
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. Return the medication to the medication cabinet.
- B. Notify the provider of the client's refusal.
- C. Document the refusal in the client's medical record.
- D. Inform the client of the potential consequences of their refusal
Correct Answer: D
Rationale: Informing about consequences first respects autonomy and may encourage compliance.
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A nurse is collecting data from a client who has diabetes mellitus. The nurse should ask which of the following questions to determine the client's ability to provide foot self-hygiene?
- A. Do you go barefoot at home?
- B. Have you noticed any problems with foot swelling?
- C. Do you have any problems taking care of your feet?
- D. Have you had a problem with ingrown toenails?
Correct Answer: C
Rationale: Asking about foot care ability directly assesses self-management in diabetes.
A nurse is assisting in the care of a client who just started receiving a blood transfusion 5 min ago. Which of the following findings should be reported first to the provider?
- A. Hyperthermia
- B. Urticaria
- C. Dyspnea
- D. Headache
Correct Answer: C
Rationale: Dyspnea is a critical sign of a transfusion reaction, requiring immediate reporting.
A nurse is caring for a client who follows a lacto-vegetarian diet. Which of the following food choices should the nurse recommend?
- A. Tuna fish
- B. Clam chowder
- C. Cheese
- D. Chicken
Correct Answer: C
Rationale: Cheese fits a lacto-vegetarian diet, which includes dairy but excludes meat and fish.
A nurse is caring for an adult client who has acute lymphocytic leukemia. The client is refusing blood products. Which of the following responses should the nurse make?
- A. Not receiving blood will slow down your recovery.
- B. I understand that you decided not to receive blood products.
- C. You need to talk with your doctor about this.
- D. Why are you refusing to receive blood products?
Correct Answer: B
Rationale: Acknowledging the client's decision respects their autonomy and opens a dialogue.
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. Episiotomy approximated, 3 cm (1.18 in) in length.
- B. Client instructed on self-care needs.
- C. Client drank adequate amounts of fluid with meals.
- D. Oral temperature elevated at 0800.
Correct Answer: A
Rationale: Specific, measurable data like episiotomy status is critical for the health record.