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A nurse is coordinating care of a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?
- A. Assess the pain level of a client who has received acetaminophen.
- B. Measure the intake and output of a client who has received furosemide.
- C. Check a client's peripheral IV site for redness or swelling.
- D. Reinforce teaching with a client about crutch-gait walking.
Correct Answer: B
Rationale: Measuring intake and output is within the AP's scope; assessment and teaching are nurse responsibilities.
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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. Family history of osteoporosis
- B. Type 1 diabetes mellitus
- C. Orthostatic hypotension
- D. BMI of 24
Correct Answer: B
Rationale: Type 1 diabetes increases cardiovascular risk due to chronic hyperglycemia affecting blood vessels.
A nurse is assisting with the care of a client who has cancer that has metastasized. The client has decided to discontinue chemotherapy treatment. Which of the following responses should the nurse make?
- A. We should talk about your decision later.
- B. Your quality of life will be compromised if you make this decision.
- C. How will you discuss this decision with your loved ones?
- D. Don't worry. Everything will work out for you.
Correct Answer: C
Rationale: Asking about discussing the decision respects autonomy and encourages communication.
A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse plan to take?
- A. Use a 10-mL syringe filled with cleansing solution.
- B. Cleanse the wound with cotton balls.
- C. Dry the wound bed with gauze squares.
- D. Hold the syringe tip 2.5 cm (1 in) above the upper end of the wound.
Correct Answer: D
Rationale: Holding the syringe 2.5 cm above provides adequate pressure for irrigation without trauma.
A nurse is caring for a client who refuses their morning dose of antihypertensive medication. The client tells the nurse, 'I'm not going to take this medication because it makes me sick and dizzy.' Which of the following actions should the nurse take first?
- A. Return the medication to the medication cabinet.
- B. Notify the provider of the client's refusal.
- C. Inform the client of the potential consequences of their refusal.
- D. Document the refusal in the client's medical record.
Correct Answer: C
Rationale: Educating about consequences first respects autonomy and may encourage compliance.
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 will move the cane forward 18 inches.
- B. I will hold the cane on my stronger side.
- C. I should wear shoes with smooth soles to help slide my weak leg forward.
- D. I should move my stronger leg forward before moving my weaker leg.
Correct Answer: B
Rationale: Holding the cane on the stronger side provides optimal support and balance for the weaker side.