Nokea
A nurse is planning to provide postmortem care for a client who requires an autopsy. Which of the following actions should the nurse plan to take?
- A. Place an identification tag on the outside of the client's shroud.
- B. Ask the assistive personnel to document the client's time of death.
- C. Wear sterile gloves when cleaning the client's body.
- D. Remove the client's dentures and give them to the client's family.
Correct Answer: A
Rationale: An ID tag ensures proper identification for autopsy purposes.
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A home health nurse is visiting a client who has advanced Alzheimer's disease. The client's partner states, 'I miss being able to go places with my friends.' Which of the following is an appropriate response by the nurse?
- A. We can discuss this when you're not feeling overwhelmed.
- B. Have you tried taking your partner with you when you go out?
- C. Tell me more about your expectations.
- D. I understand how you feel. I've had a relative go through the same thing.
Correct Answer: C
Rationale: Asking about expectations opens dialogue and shows empathy, supporting the partner's needs.
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 preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?
- A. Inject air into the ampule prior to drawing the medication into a syringe.
- B. Add 0.5 mL of diluent to the medication.
- C. Use a filter needle to aspirate the medication.
- D. Cleanse the tip of the ampule with an alcohol swab after opening.
Correct Answer: C
Rationale: Using a filter needle ensures no glass contaminants are administered.
A nurse is reinforcing teaching about advance directives with a client who has terminal colorectal cancer. Which of the following statements by the client indicates an understanding of the teaching?
- A. I'm glad to have the opportunity to choose what kind of care I receive while I still can.
- B. I can't change my mind about the care I will receive once I sign my living will.
- C. Once I fill out my living will, there will be a 1-month delay before it is legally binding.
- D. If I want life support, I'll need to sign a separate consent form first.
Correct Answer: A
Rationale: This reflects understanding that advance directives allow care choices while capable.
A nurse in a long-term care facility is preparing to administer medications to a client who has advanced dementia and does not have an identification band. Which of the following actions should the nurse take to verify the client's identity?
- A. Review the client's photograph in the medical record.
- B. Request an assistive personnel to identify the client.
- C. Ask the client to state their room number.
- D. Have the client state their phone number.
Correct Answer: A
Rationale: A photograph ensures accurate identification, critical for a client with dementia unable to self-identify.