Nokea
A nurse is caring for a young adult client who is postoperative and requires physical therapy, pain management, and dietary advancement. The nurse enters the client's room and finds them dressing and stating that they are going home. Which of the following actions should the nurse take?
- A. Administer a sedative medication to the client.
- B. Explain to the client that they cannot leave until the surgeon discharges them.
- C. Have the client sign an against medical advice form.
- D. Tell the client that the surgeon will prescribe restraints if they try to leave.
Correct Answer: C
Rationale: Signing an AMA form documents the client's informed decision to leave against advice.
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A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?
- A. Inject air into the ampule prior to drawing the medication into a syringe.
- B. Add 0.5 mL of diluent to the medication.
- C. Use a filter needle to aspirate the medication.
- D. Cleanse the tip of the ampule with an alcohol swab after opening.
Correct Answer: C
Rationale: Using a filter needle ensures no glass contaminants are administered.
A nurse is caring for a client who is postoperative following a laminectomy. Which of the following actions should the nurse take when repositioning the client?
- A. Place the client's arms above her head prior to logrolling.
- B. Place the client in semi-Fowler's position prior to logrolling.
- C. Place the bed in the lowest position before logrolling the client.
- D. Place a pillow between the client's legs prior to logrolling.
Correct Answer: D
Rationale: A pillow maintains spinal alignment during logrolling post-laminectomy.
A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? (Select all that apply.)
- A. A client receives burns from a heating pad.
- B. A client reports being dissatisfied with the temperature of the meals provided.
- C. A client becomes disoriented and falls out of bed.
- D. A client’s visitor becomes dizzy and faints in the client's room.
- E. A client is unable to afford the physical therapy that the provider recommends.
Correct Answer: A,C,D
Rationale: A: Injury requires reporting. C: Fall indicates safety issue. D: Visitor incident needs documentation.
A nurse is assisting in the transfer of a client who has left-sided weakness from a bed to a chair. Which of the following actions should the nurse take?
- A. Flex hips and knees when assisting the client to a standing position.
- B. Pivot on the foot farthest from the bed when assisting the client into the chair.
- C. Stand on the client's stronger side when moving the client into the chair.
- D. Raise the bed to waist level before moving the client.
Correct Answer: A
Rationale: Flexing hips and knees uses proper mechanics, reducing injury risk during transfer.
A nurse is collecting data from a client who is 2 days postoperative following the placement of a colostomy. Which of the following findings should the nurse report to the provider?
- A. The stoma is draining a small amount of liquid stool.
- B. The stoma protrudes slightly from the abdomen.
- C. The stoma appears dark in color.
- D. The stoma bleeds lightly when touched.
Correct Answer: C
Rationale: A dark stoma suggests ischemia or necrosis, requiring urgent reporting.