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. Apply clean gloves.
- B. Prick the side of the client's finger.
- C. Squeeze the client's finger until a blood drop forms.
- D. Cleanse the client's finger with an iodine swab.
- E. Elevate the client's hand above the level of the heart
Correct Answer: A,B
Rationale: A: Gloves ensure safety. B: Side of finger is less painful and effective for blood collection.
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A nurse is collecting data from a client who is immobile and has a potential deep-vein thrombosis. Which of the following findings should the nurse report to the provider?
- A. Calf swelling
- B. Bradycardia
- C. Tortuous veins
- D. Clammy skin
Correct Answer: A
Rationale: Calf swelling is a key sign of deep-vein thrombosis, requiring immediate reporting for intervention.
A charge nurse on a long-term care unit is working with an assistive personnel who states, 'I am tired of all the changes on this unit. If things don't improve soon, I'm requesting a transfer.' Which of the following responses should the charge nurse make?
- A. Why don't you just file a formal complaint with Human Resources?
- B. Please, try to wait a little longer. Things will get better soon.
- C. There has been too much complaining about these changes.
- D. So, you are upset about all of the recent changes on the unit?
Correct Answer: D
Rationale: Reflecting the AP's feelings fosters communication and addresses concerns constructively.
A nurse is assigning a semiprivate room to a client who has herpes zoster. Which of the following roommates is appropriate?
- A. A client who has tuberculosis
- B. A client who has rubella
- C. A client who has had varicella
- D. A client who is HIV-positive
Correct Answer: C
Rationale: A client with prior varicella is immune to herpes zoster (same virus), minimizing transmission risk.
A nurse is reinforcing teaching with a client about advance directives. Which of the following client statements indicates an understanding of the teaching?
- A. I can name my sibling as my designee in my durable power of attorney for health care.
- B. I need to create advance directives so that I can donate my organs.
- C. My advance directives can be enforced once my attorney approves them.
- D. A family member will need to witness my signature on my living will.
Correct Answer: A
Rationale: Naming a sibling as a designee is a correct use of a durable power of attorney for health care.
A nurse is assisting with the care of a client who has cancer that has metastasized. The client has decided to discontinue chemotherapy treatment. Which of the following responses should the nurse make?
- A. We should talk about your decision later.
- B. Your quality of life will be compromised if you make this decision.
- C. How will you discuss this decision with your loved ones?
- D. Don't worry. Everything will work out for you.
Correct Answer: C
Rationale: Asking about discussing the decision respects autonomy and encourages communication.