Nokea
A nurse is preparing to administer medications to a client. Which of the following pieces of information should the nurse use as a client identifier?
- A. Photograph
- B. Medical diagnosis
- C. Age
- D. Room number
Correct Answer: A
Rationale: A photograph, combined with other identifiers like name and birthdate, ensures positive patient identification.
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A nurse is caring for an adult client who has acute lymphocytic leukemia. The client is refusing blood products. Which of the following responses should the nurse make?
- A. I understand that you decided not to receive blood products.
- B. You need to talk with your doctor about this.
- C. Not receiving blood will slow down your recovery.
- D. Why are you refusing to receive blood products?
Correct Answer: A
Rationale: Acknowledging the decision respects the client’s autonomy.
A nurse is reinforcing teaching about beginning an exercise program with an older adult client who is at risk for osteoporosis. Which of the following activities should the nurse recommend?
- A. Passive range-of-motion exercise
- B. Bowling
- C. Walking
- D. Jogging
Correct Answer: C
Rationale: Walking is a weight-bearing, low-impact exercise that helps improve bone density and is safe for osteoporosis prevention.
A nurse is reinforcing discharge teaching with a male client who has an indwelling urinary catheter. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will apply antiseptic ointment to the tip of my penis.
- B. I will keep the drainage bag below the level of my waist.
- C. I will empty my drainage bag once a day.
- D. I will clamp the tube when I go for a walk.
Correct Answer: B
Rationale: Keeping the drainage bag below waist level prevents backflow and reduces infection risk.
A nurse is collecting data from a client who is 2 days postoperative following the placement of a colostomy. Which of the following findings should the nurse report to the provider?
- A. The stoma bleeds lightly when touched.
- B. The stoma appears dark in color.
- C. The stoma protrudes slightly from the abdomen.
- D. The stoma is draining a small amount of liquid stool.
Correct Answer: B
Rationale: A dark stoma suggests ischemia or necrosis, requiring urgent reporting.
A nurse is preparing to reinforce teaching with a client who has expressive aphasia. Which of the following actions should the nurse plan to take?
- A. Provide the teaching without expecting the client to respond.
- B. Determine the client's ability to use a communication board
- C. Speak with a loud voice while providing the information.
- D. Avoid the use of facial gestures during the instructions.
Correct Answer: B
Rationale: A communication board aids clients with expressive aphasia in conveying needs, enhancing teaching effectiveness.