Nokea
A nurse is caring for an adult client who has a developmental disability. The client requires an emergency appendectomy, and the staff cannot reach the appointed guardian. Which of the following is an appropriate action for the nurse to take?
- A. Obtain consent from the client.
- B. Request that the provider sign the consent form.
- C. Postpone the procedure until the staff contacts the guardian.
- D. Prepare the client for surgery with implied consent.
Correct Answer: D
Rationale: Implied consent applies in emergencies when the guardian is unavailable, allowing life-saving treatment.
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A nurse is caring for a client who has a new colostomy. The client refuses to participate in her ostomy care, saying, 'I'm not touching that thing.' Which of the following actions should the nurse take?
- A. Request that someone from the client's family participate in the care.
- B. Ask the client to explain her feelings.
- C. Explain why her participation is important.
- D. Tell the client that it is safe to touch her ostomy.
- E. Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin.
Correct Answer: B
Rationale: Exploring feelings addresses emotional barriers, promoting eventual acceptance of care.
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 bleeds lightly when touched.
- D. The stoma appears dark in color.
Correct Answer: D
Rationale: A dark stoma indicates potential necrosis or ischemia, requiring immediate provider attention.
A nurse is observing an assistive personnel (AP) provide postmortem care for a client prior to visitation by their loved ones. Which of the following actions by the AP requires intervention by the nurse?
- A. Washing the client's face
- B. Gathering the client's personal belongings
- C. Removing the client's dentures from their mouth
- D. Closing the client's eyes
Correct Answer: C
Rationale: Removing dentures alters appearance unnaturally; they should remain unless otherwise specified.
A nurse is caring for a client who has insomnia. Which of the following actions should the nurse take?
- A. Administer prescribed diuretics in the evening
- B. Provide the client with snug-fitting nightwear
- C. Keep the door to the client's room closed
- D. Use overhead lighting when checking equipment
Correct Answer: C
Rationale: Closing the door reduces noise, promoting sleep; other options may disrupt it.
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 apply antiseptic ointment to the tip of my penis.
- B. I will clamp the tube when I go for a walk.
- C. I will keep the drainage bag below the level of my waist.
- D. I will empty my drainage bag once a day.
Correct Answer: C
Rationale: Keeping the bag below waist level prevents urine backflow, reducing infection risk.