Nokea
A nurse is collecting data from an older adult client who lives alone. Which of the following findings should the nurse identify as the priority?
- A. The client verbalizes regret about never marrying.
- B. The client is sedentary throughout most of the day.
- C. The client has no living family.
- D. The client has poorly fitting dentures.
Correct Answer: D
Rationale: Poorly fitting dentures can impair nutrition, posing an immediate health risk.
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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 a medical interpreter service on behalf of a client
- B. To a family member when the client is not available
- C. To an employer for a pre-employment screening
- D. To an insurance agency in regard to a life insurance policy
Correct Answer: A
Rationale: Disclosure to an interpreter is permissible under HIPAA to facilitate care.
A nurse is reinforcing teaching with a client about the use of a quad cane. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should wear shoes with smooth soles to help slide my weak leg forward.
- B. I should move my stronger leg forward before moving my weaker leg.
- C. I will move the cane forward 18 inches.
- D. I will hold the cane on my stronger side.
Correct Answer: B
Rationale: Moving the stronger leg first is correct for safe ambulation with a quad cane.
A nurse is preparing to set up a sterile field to change a sterile dressing on a client's abdominal wound. Identify the sequence of steps the nurse should take.
- A. Grasp the outermost flap of the sterile kit while opening away from the body.
- B. Open the innermost lower flap of the sterile kit while standing away from the sterile field.
- C. Open each side flap of the sterile kit individually while pulling to the side.
- D. Prepare a dry work surface above the waist level.
- E. Open the outside cover of the sterile kit and remove the dust cover.
Correct Answer: D,E,A,C,B
Rationale: D: Set up surface. E: Remove cover. A: Open outermost flap. C: Open side flaps. B: Open innermost flap maintains sterility.
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. Keep the specimen in a warm area.
- C. Avoid placing toilet tissue in the bedpan after defecation.
- D. Place 1.3 cm (0.5 in) of formed stool into a culture tube.
Correct Answer: C
Rationale: Avoiding toilet tissue prevents contamination of the stool specimen.
A nurse in a provider's office is reviewing data from a client's medical record. Which of the following findings should the nurse identify as a risk factor for cardiovascular disease?
- A. Orthostatic hypotension
- B. Type 1 diabetes mellitus
- C. Family history of osteoporosis
- D. BMI of 24
Correct Answer: B
Rationale: Type 1 diabetes increases cardiovascular risk due to chronic hyperglycemia damaging blood vessels.