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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. Notify the provider of the client's refusal.
- B. Document the refusal in the client's medical record.
- C. Inform the client of the potential consequences of their refusal.
- D. Return the medication to the medication cabinet.
Correct Answer: C
Rationale: Informing about consequences first educates the client, supporting informed decision-making.
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A nurse is preparing to instill an otic medication for an adult client. Which of the following actions should the nurse take?
- A. Pull the client's pinna downward and back.
- B. Cleanse the client's outer ear with isopropyl alcohol to remove wax.
- C. Hold the ear dropper 1 cm (0.5 in) from the client's ear.
- D. Request the client remain supine for 10 min following administration.
Correct Answer: C
Rationale: Holding the dropper 1 cm away ensures accurate delivery without contaminating the ear canal.
A nurse is reinforcing teaching about beginning an exercise program with an older adult client who is at risk for osteoporosis. Which of the following activities should the nurse recommend?
- A. Bowling
- B. Walking
- C. Passive range-of-motion exercise
- D. Jogging
Correct Answer: B
Rationale: Walking, a weight-bearing exercise, strengthens bones, reducing osteoporosis risk safely.
A nurse is reinforcing discharge teaching with a male client who has an indwelling urinary catheter. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will empty my drainage bag once a day.
- B. I will apply antiseptic ointment to the tip of my penis.
- C. I will keep the drainage bag below the level of my waist.
- D. I will clamp the tube when I go for a walk.
Correct Answer: C
Rationale: Keeping the bag below waist level prevents urine backflow, reducing infection risk.
A nurse is caring for a client who requires a sterile dressing change. The nurse should recognize that the surgical field has been contaminated if which of the following actions occur?
- A. Unnecessary sterile items are placed on the field.
- B. The sterile solution is poured with the bottle held over the field.
- C. The handle of a pair of sterile scissors is resting 5 cm (2 in) from the field's edge.
- D. A pair of sterile forceps is allowed to rest in a container of sterile water on the field.
Correct Answer: B
Rationale: Pouring over the field risks contamination from the bottle, breaching sterility.
A nurse is caring for a client who is postoperative and is preparing to walk for the first time in several days. Which of the following instructions should the nurse give the client to prevent orthostatic hypotension?
- A. Increase your intake of protein.
- B. Use your incentive spirometer.
- C. Perform regular isometric exercises.
- D. Dangle your legs over the side of the bed.
Correct Answer: D
Rationale: Dangling legs before standing allows gradual adjustment to upright posture, minimizing orthostatic hypotension risk.