Nokea
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 is repressed.
- B. A client whose grief response begins following a terminal diagnosis.
- C. A client whose grief response leads to self-destructive behaviors.
- D. A client whose grief response is triggered by a secondary loss.
Correct Answer: C
Rationale: Exaggerated grief involves intense, harmful reactions like self-destructive behaviors, impairing function.
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A nurse is caring for a postoperative male client in the surgical unit. Click to highlight the documentation in the client's medical record that requires further action by the nurse. Select all that apply
- A. Respiratory rate 10/min
- B. Pulse oximetry 88% on room air
- C. Blood pressure 99/46 mm Hg
- D. Morphine 10 mg administered subcutaneously
Correct Answer: A,B,D
Rationale: A: Low respiratory rate suggests opioid depression. B: Low SaO2 indicates hypoxemia. D: Morphine dose may need reassessment due to side effects.
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. Avoid placing toilet tissue in the bedpan after defecation.
- B. Urinate after the specimen collection.
- C. Place 1.3 cm (0.5 in) of formed stool into a culture tube.
- D. Keep the specimen in a warm area.
Correct Answer: A
Rationale: Avoiding toilet tissue prevents contamination, ensuring specimen integrity.
A nurse is setting up a sterile field in a client's room. Which of the following actions should the nurse take?
- A. Placing the cap of a sterile solution on a clean surface with the inside facing down.
- B. Placing a sterile instrument within 1.3 cm (0.5 in) of the edge of the sterile field.
- C. Opening the top flap of the sterile tray package away from their body.
- D. Dropping sterile objects onto the field from a height of 5 cm (2 in).
Correct Answer: C
Rationale: Opening the flap away prevents contamination from the nurse’s body.
A nurse is reinforcing discharge teaching about fecal occult blood testing with a client. Which of the following instructions should the nurse include in the teaching?
- A. Place a thick layer of stool on the specimen card.
- B. Urinate prior to collecting the stool specimen.
- C. Discontinue supplements containing vitamin C 24 hours before the test.
- D. Refrain from consuming pork 7 days before the test.
Correct Answer: C
Rationale: Vitamin C can cause false negatives, so discontinuing it ensures accuracy.
A nurse is wearing sterile gloves in preparation for assisting with a client's sterile procedure. While waiting for the procedure to begin, how should the nurse position their hands?
- A. Place one hand over the other against the part of the gown covering their upper body.
- B. Clasp their hands together in a relaxed position behind their body at their waist.
- C. Keep their arms at the sides of their body with their hands in a relaxed position.
- D. Interlock their fingers and hold their hands away from their body above their waist.
Correct Answer: D
Rationale: Interlocking fingers above the waist prevents contamination of sterile gloves.