Nokea
A nurse is caring for an adult client who has acute lymphocytic leukemia. The client is refusing blood products. Which of the following responses should the nurse make?
- A. You need to talk with your doctor about this.
- B. Not receiving blood will slow down your recovery.
- C. I understand that you decided not to receive blood products.
- D. Why are you refusing to receive blood products?
Correct Answer: C
Rationale: Acknowledging the refusal respects autonomy while opening dialogue.
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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. Passive range-of-motion exercise
- C. Jogging
- D. Walking
Correct Answer: D
Rationale: Walking is weight-bearing, promoting bone density safely for osteoporosis prevention.
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. The handle of a pair of sterile scissors is resting 5 cm (2 in) from the field's edge.
- B. A pair of sterile forceps is allowed to rest in a container of sterile water on the field.
- C. Unnecessary sterile items are placed on the field.
- D. The sterile solution is poured with the bottle held over the field.
Correct Answer: D
Rationale: Pouring with the bottle over the field risks contamination from the non-sterile bottle.
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.
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 insurance agency in regard to a life insurance policy
- B. To an employer for a pre-employment screening
- C. To a medical interpreter service on behalf of a client
- D. To a family member when the client is not available
Correct Answer: C
Rationale: Disclosure to an interpreter is allowed under HIPAA to facilitate care, unlike the other scenarios.
A nurse is reinforcing teaching with a client about using guided imagery to manage chronic pain. Which of the following statements by the client indicates an understanding of this technique?
- A. I'll use focused breathing to control my pain.
- B. I'll listen to my favorite music to take my mind off the pain.
- C. I'll learn to notice the sensation of muscle tension.
- D. I'll think about my grandfather's farm to reduce pain.
Correct Answer: D
Rationale: Guided imagery involves visualizing a calming scene (e.g., a farm) to distract from pain.