Nokea
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. Removing the client's dentures from their mouth
- B. Washing the client's face
- C. Closing the client's eyes
- D. Gathering the client's personal belongings
Correct Answer: A
Rationale: Removing dentures is a nursing task to ensure proper handling, requiring intervention.
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A nurse is planning to obtain a client's oxygen saturation. Which of the following might influence the result of this test?
- A. The client is wearing nail polish.
- B. The client has an elevated hemoglobin level.
- C. The client has a fever.
- D. The client is wearing a ring.
Correct Answer: A
Rationale: Nail polish can block light in pulse oximetry, leading to inaccurate low readings.
A nurse is collecting data from a client who is immobile and has a potential deep-vein thrombosis. Which of the following findings should the nurse report to the provider?
- A. Clammy skin
- B. Tortuous veins
- C. Bradycardia
- D. Calf swelling
Correct Answer: D
Rationale: Calf swelling is a key sign of DVT, indicating possible venous obstruction needing urgent evaluation.
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 family member when the client is not available
- B. To an employer for a pre-employment screening
- C. To an insurance agency in regard to a life insurance policy
- D. To a medical interpreter service on behalf of a client
Correct Answer: D
Rationale: Disclosure to an interpreter facilitates care and is permitted under HIPAA without consent.
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. Notify the provider of the client's refusal.
- B. Document the refusal in the client's medical record.
- C. Inform the client of the potential consequences of their refusal.
- D. Return the medication to the medication cabinet.
Correct Answer: C
Rationale: Informing about consequences first educates the client, supporting informed decision-making.
A nurse is caring for a client who is confused and has a prescription for wrist restraints. Which of the following actions should the nurse take?
- A. Secure the restraints with a square knot.
- B. Check the client's range of motion every 6 hr.
- C. Make sure two fingers fit under the restraints.
- D. Request a prescription renewal from the provider every 36 hr.
Correct Answer: C
Rationale: Ensuring two fingers fit prevents excessive tightness, promoting circulation and safety.