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A nurse is collecting data from a client who reports an inability to cope because of their recent job loss. Which of the following actions should the nurse take?
- A. Tell the client to think about something else.
- B. Ask the client to describe their support system.
- C. Ask the client why they're unable to cope.
- D. Tell the client that everything will be okay.
Correct Answer: B
Rationale: Assessing the support system identifies resources to help the client cope.
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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 on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery. The client's BP was 126/72 mm Hg 15 min ago. The nurse now finds that the client's BP is 176/96 mm Hg. Which of the following actions should the nurse take?
- A. Use a narrower cuff to repeat the BP measurement.
- B. Request a prescription for an antihypertensive medication.
- C. Deflate the cuff faster when repeating the BP measurement.
- D. Measure the client's BP in the other arm.
Correct Answer: D
Rationale: Measuring in the other arm verifies the sudden BP increase, ruling out measurement error.
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 protrudes slightly from the abdomen.
- B. The stoma appears dark in color.
- C. The stoma bleeds lightly when touched.
- D. The stoma is draining a small amount of liquid stool.
Correct Answer: B
Rationale: A dark-colored stoma indicates potential ischemia or necrosis, requiring immediate reporting.
A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? (Select all that apply.)
- A. A client reports being dissatisfied with the temperature of the meals provided.
- B. A client receives burns from a heating pad.
- C. A client becomes disoriented and falls out of bed.
- D. A client is unable to afford the physical therapy that the provider recommends.
- E. A client's visitor becomes dizzy and faints in the client's room.
Correct Answer: B,C,E
Rationale: B: Burns indicate harm. C: Falls require reporting. E: Visitor fainting is an unexpected event.
A nurse is reinforcing teaching with a client about how to collect a stool specimen. Which of the following instructions should the nurse include?
- A. Urinate after the specimen collection.
- B. Place 1.3 cm (0.5 in) of formed stool into a culture tube.
- C. Keep the specimen in a warm area.
- D. Avoid placing toilet tissue in the bedpan after defecation.
Correct Answer: D
Rationale: Avoiding toilet tissue prevents contamination of the stool specimen.