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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. Return the medication to the medication cabinet.
- B. Notify the provider of the client's refusal.
- C. Inform the client of the potential consequences of their refusal.
- D. Document the refusal in the client's medical record.
Correct Answer: C
Rationale: Educating about consequences first respects autonomy and may encourage compliance.
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A nurse is collecting data from an older adult client who lives alone. Which of the following findings should the nurse identify as the priority?
- A. The client verbalizes regret about never marrying.
- B. The client has poorly fitting dentures.
- C. The client has no living family.
- D. The client is sedentary throughout most of the day.
Correct Answer: B
Rationale: Poorly fitting dentures impair nutrition, a priority health risk requiring immediate attention.
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 responding, enhancing understanding.
A nurse is reinforcing teaching with a client about advance directives. Which of the following client statements indicates an understanding of the teaching?
- A. I can name my sibling as my designee in my durable power of attorney for health care.
- B. I need to create advance directives so that I can donate my organs.
- C. My advance directives can be enforced once my attorney approves them.
- D. A family member will need to witness my signature on my living will.
Correct Answer: A
Rationale: Naming a sibling as a designee is a correct use of a durable power of attorney for health care.
A nurse is caring for a client who is confused and has a prescription for wrist restraints. Which of the following actions should the nurse take?
- A. Check the client's range of motion every 6 hr.
- B. Make sure two fingers fit under the restraints.
- C. Secure the restraints with a square knot.
- D. Request a prescription renewal from the provider every 36 hr.
Correct Answer: B
Rationale: Ensuring two fingers fit under restraints prevents excessive tightness and maintains circulation.
A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse plan to take?
- A. Use a 10-mL syringe filled with cleansing solution.
- B. Cleanse the wound with cotton balls.
- C. Dry the wound bed with gauze squares.
- D. Hold the syringe tip 2.5 cm (1 in) above the upper end of the wound.
Correct Answer: D
Rationale: Holding the syringe 2.5 cm above provides adequate pressure for irrigation without trauma.