Nokea
A nurse is preparing to insert an indwelling urinary catheter and is verifying the client's express consent for this procedure. Which of the following actions should the nurse take?
- A. Obtain verbal consent from the client.
- B. Witness the client's signature on a consent form.
- C. Check the medical record for the client's signature on a previous consent form.
- D. Have another nurse co-sign the client's consent
Correct Answer: B
Rationale: Witnessing the signature ensures informed consent is documented per protocol.
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A nurse is reviewing the medical record of a client. Click to highlight below the findings that require immediate follow-up.
- A. Neurological: Alert and oriented to person, place, and time; deep tendon reflexes 4+
- B. Musculoskeletal: Generalized weakness with equal bilateral muscle strength and mild leg cramping
- C. Respiratory: Lungs clear
- D. Cardiovascular: Heart rate irregular, Heart rate 95/min
- E. Gastrointestinal: Bowel sounds hyperactive x 4 quadrants
Correct Answer: D
Rationale: An irregular heart rate (D) requires immediate follow-up due to potential arrhythmia risks.
A nurse in a provider's office is collecting data from an older adult client. The client states that he is having difficulty sleeping. Which of the following strategies should the nurse recommend to promote sleep?
- A. Take a 1-hour nap each day.
- B. Drink a glass of milk before bedtime.
- C. Take a long walk before bedtime.
- D. Watch television in bed.
Correct Answer: B
Rationale: Milk contains tryptophan, which promotes sleep.
A nurse is collecting data from a client who reports feeling short of breath and notes that the client's SpO2 level is 88% while on room air. Which of the following actions should the nurse take first?
- A. Recheck the client's SaO2 level after having the client cough and clear their throat.
- B. Notify the charge nurse of the client's condition.
- C. Review the client's most recent SaO2 level in the medical record.
- D. Check the client's medical records to see which medications were recently admitted.
Correct Answer: A
Rationale: Rechecking SpO2 after clearing the airway rules out temporary obstruction as the cause.
A nurse is caring for a client who has a new colostomy. The client refuses to participate in her ostomy care, saying, 'I'm not touching that thing.' Which of the following actions should the nurse take?
- A. Tell the client that it is safe to touch her ostomy.
- B. Request that someone from the client's family participate in the care.
- C. Ask the client to explain her feelings.
- D. Explain why her participation is important.
Correct Answer: C
Rationale: Exploring feelings helps address emotional barriers to self-care.
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. Room number
- D. Age
Correct Answer: A
Rationale: A photograph is a reliable identifier per safety standards.