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. Not receiving blood will slow down your recovery.
- B. I understand that you decided not to receive blood products.
- C. You need to talk with your doctor about this.
- D. Why are you refusing to receive blood products?
Correct Answer: B
Rationale: Acknowledging the client's decision respects their autonomy and opens a dialogue.
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A nurse is caring for a client and observes a nurse from another unit reviewing the client's medical record. Which of the following actions should the nurse take?
- A. Tell the nurse that permission from the risk manager is required to view the client's record.
- B. Contact facility security to remove the nurse from the unit.
- C. Complete an incident report about the breach of confidentiality.
- D. Remind the nurse that only staff caring for the client may access the client's record.
Correct Answer: D
Rationale: This action reinforces HIPAA compliance without escalating unnecessarily.
A nurse is caring for a client who has a terminal illness. The client asks what type of care will be provided as death approaches. Which of the following statements should the nurse make first?
- A. You can allow your family to visit as often as you wish.
- B. Tell me your expectations about activities related to the end-of-life.
- C. We can talk to the provider about incorporating nonpharmacological pain management in your care.
- D. You can provide the name of a spiritual support person we can contact for you.
Correct Answer: B
Rationale: Understanding the client's expectations guides personalized end-of-life care.
A nurse is assigning a semiprivate room to a client who has herpes zoster. Which of the following roommates is appropriate?
- A. A client who has rubella
- B. A client who has had varicella
- C. A client who is HIV-positive
- D. A client who has tuberculosis
Correct Answer: B
Rationale: A client with prior varicella is immune to herpes zoster, reducing transmission risk.
A nurse is reinforcing teaching about advance directives with a client who has terminal colorectal cancer. Which of the following statements by the client indicates an understanding of the teaching?
- A. I'm glad to have the opportunity to choose what kind of care I receive while I still can.
- B. If I want life support, I'll need to sign a separate consent form first.
- C. I can't change my mind about the care I will receive once I sign my living will.
- D. Once I fill out my living will, there will be a 1-month delay before it is legally binding.
Correct Answer: A
Rationale: Advance directives allow clients to specify care preferences, reflecting autonomy.
A nurse is preparing to obtain a capillary blood specimen from a client. Which of the following actions should the nurse take? (Select all that apply)
- A. Squeeze the client's finger until a blood drop forms
- B. Prick the side of the client's finger.
- C. Elevate the client's hand above the level of the heart
- D. Cleanse the client's finger with an iodine swab
- E. Using clean gloves
Correct Answer: B, E
Rationale: B: Pricking the side avoids painful areas. E: Clean gloves ensure infection control.