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. Prepare the client for surgery with implied consent.
- D. Postpone the procedure until the staff contacts the guardian.
Correct Answer: C
Rationale: Implied consent applies in emergencies when delay risks life, and the guardian is unavailable.
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A nurse is collecting data from a client who is immobile and has a potential deep-vein thrombosis. Which of the following findings should the nurse report to the provider?
- A. Clammy skin
- B. Tortuous veins
- C. Bradycardia
- D. Calf swelling
Correct Answer: D
Rationale: Calf swelling is a key sign of DVT, indicating possible venous obstruction needing urgent evaluation.
A nurse is preparing to administer medications to a client. Which of the following pieces of information should the nurse use as a client identifier?
- A. Room number
- B. Medical diagnosis
- C. Age
- D. Photograph
Correct Answer: D
Rationale: A photograph provides a unique, visual confirmation of identity for safe medication administration.
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.
A nurse is reinforcing teaching with a client who has an ostomy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will apply a thin layer of talc powder around the stoma before placing the appliance.
- B. I will cut an opening in the skin barrier that is 1â„2 inch larger than the stoma.
- C. I will press on the skin barrier for 30 seconds to ensure that it adheres.
- D. I will clean around the stoma with a moisturizing soap.
Correct Answer: C
Rationale: Pressing the barrier ensures adhesion, preventing leaks and maintaining skin integrity.
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.