Nokea
A nurse is preparing to obtain a capillary blood specimen from a client. Which of the following actions should the nurse take? (Select all that apply.)
- A. Squeeze the client's finger until a blood drop forms.
- B. Prick the side of the client's finger.
- C. Elevate the client's hand above the level of the heart.
- D. Cleanse the client's finger with an iodine swab.
- E. Apply clean gloves.
Correct Answer: B,E
Rationale: B: Pricking the side is less painful and safer. E: Gloves prevent contamination and ensure safety.
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A nurse is collecting data from a client who has hypomagnesemia. Which of the following findings should the nurse identify as a positive Chvostek's sign?
- A. A
- B. B
- C. C
- D. D
Correct Answer: C
Rationale: A positive Chvostek's sign (twitching of facial muscles when tapping the facial nerve) is associated with hypomagnesemia; assumed as C due to incomplete options.
A nurse is contributing to a community center's in-service program about early detection of breast cancer. Which of the following recommendations should the nurse make for female clients who do not have a family history of breast cancer?
- A. You should start receiving mammograms as early as age 40.
- B. You should receive a breast ultrasound every 3 years after age 50.
- C. You should start performing monthly breast self-examinations at age 35.
- D. You should receive a breast examination from your provider each year after age 30.
Correct Answer: A
Rationale: Mammograms starting at age 40 are recommended for average-risk women.
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 a teaching plan regarding proper lifting with a client. Which of the following strategies should the nurse include to prevent back injury when lifting an object?
- A. Tighten the abdominal muscles.
- B. Bend at the waist.
- C. Keep legs straight.
- D. Hold object away from the body.
Correct Answer: A
Rationale: Tightening abdominal muscles stabilizes the core, reducing back strain.
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. Gathering the client's personal belongings
- B. Closing the client's eyes
- C. Washing the client's face
- D. Removing the client's dentures from their mouth
Correct Answer: D
Rationale: Dentures should remain in place to maintain facial structure for family visitation.