Nokea
A nurse is collecting data from a client who reports feeling short of breath and notes that the client's SpO2 level is 88% while on room air. Which of the following actions should the nurse take first?
- A. Recheck the client's SaO2 level after having the client cough and clear their throat.
- B. Notify the charge nurse of the client's condition.
- C. Review the client's most recent SaO2 level in the medical record.
- D. Check the client's medical records to see which medications were recently admitted.
Correct Answer: A
Rationale: Rechecking SpO2 after clearing the airway rules out temporary obstruction as the cause.
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A nurse is reinforcing teaching with a client about advance directives. Which of the following client statements indicates an understanding of the teaching?
- A. I need to create advance directives so that I can donate my organs.
- B. I can name my sibling as my designee in my durable power of attorney for health care.
- C. My advance directives can be enforced once my attorney approves them.
- D. A family member will need to witness my signature on my living will.
Correct Answer: B
Rationale: Naming a designee is a key component of a durable power of attorney.
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.
A nurse is observing an assistive personnel (AP) provide postmortem care for a client prior to visitation by their loved ones. Which of the following actions by the AP requires intervention by the nurse?
- A. Washing the client's face
- B. Gathering the client's personal belongings
- C. Closing the client's eyes
- D. Removing the client's dentures from their mouth
Correct Answer: D
Rationale: Removing dentures distorts facial appearance, requiring intervention.
A nurse is participating in a group discussion about complicated grief associated with loss. Which of the following should the nurse identify as an example of exaggerated grief?
- A. A client whose grief response begins following a terminal diagnosis
- B. A client whose grief response is repressed
- C. A client whose grief response is triggered by a secondary loss
- D. A client whose grief response leads to self-destructive behaviors
Correct Answer: D
Rationale: Exaggerated grief involves extreme, self-destructive reactions beyond normal grieving.
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. Jogging
- C. Passive range-of-motion exercise
- D. Walking
Correct Answer: D
Rationale: Walking is weight-bearing and safe, promoting bone health.