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. Postpone the procedure until the staff contacts the guardian.
- B. Obtain consent from the client.
- C. Prepare the client for surgery with implied consent.
- D. Request that the provider sign the consent form.
Correct Answer: C
Rationale: In emergencies, implied consent is appropriate when the guardian is unavailable.
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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. Document the refusal in the client's medical record.
- D. Inform the client of the potential consequences of their refusal
Correct Answer: D
Rationale: Informing about consequences first respects autonomy and may encourage compliance.
A nurse is contributing to a community center's in-service program about early detection of breast cancer. Which of the following recommendations should the nurse make for female clients who do not have a family history of breast cancer?
- A. You should receive a breast examination from your provider each year after age 30.
- B. You should start receiving mammograms as early as age 40.
- C. You should receive a breast ultrasound every 3 years after age 50.
- D. You should start performing monthly breast self-examinations at age 35.
Correct Answer: A
Rationale: Annual clinical breast exams are recommended starting at age 30 for early detection.
A nurse is reinforcing teaching with a group of newly licensed nurses regarding client confidentiality. In which of the following situations can the nurse disclose health information without the client's written consent?
- A. To an employer for a pre-employment screening
- B. To an insurance agency in regard to a life insurance policy
- C. To a family member when the client is not available
- D. To a medical interpreter service on behalf of a client
Correct Answer: D
Rationale: Disclosure to an interpreter is permitted under HIPAA to facilitate care.
A nurse is caring for a client who is postpartum. Which of the following documentations should the nurse include in the client's health record?
- A. Episiotomy approximated, 3 cm (1.18 in) in length.
- B. Client instructed on self-care needs.
- C. Client drank adequate amounts of fluid with meals.
- D. Oral temperature elevated at 0800.
Correct Answer: A
Rationale: Specific, measurable data like episiotomy status is critical for the health record.
The nurse is reinforcing discharge teaching with the client and their caregiver. Which of the following information should the nurse include? Select all that apply.
- A. Ensure the oxygen delivery system is at least 8 feet from any heat source
- B. Adjust the oxygen flow rate as needed to ease breathing.
- C. Take antibiotic medication with or without food.
- D. Decrease the steroid dose each day.
- E. Take antibiotics for 10 days.
- F. Store the oxygen cylinder wrench with the oxygen tank.
- G. Take steroid medication in the morning.
Correct Answer: A,E,F,G
Rationale: A: Safety precaution. E: Standard antibiotic duration. F: Accessibility for emergencies. G: Morning steroids reduce adrenal suppression.