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. Using clean gloves
Correct Answer: B, E
Rationale: B: Pricking the side avoids painful areas. E: Clean gloves ensure infection control.
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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. There has been too much complaining about these changes.
- B. Please, try to wait a little longer. Things will get better soon.
- C. So, you are upset about all of the recent changes on the unit?
- D. Why don't you just file a formal complaint with Human Resources?
Correct Answer: C
Rationale: Reflecting the AP's feelings encourages open communication.
A nurse is caring for an older adult client who has a hearing aid. Which of the following actions should the nurse take when the client reports hearing a whistling sound from the hearing aid?
- A. Soak the hearing aid in warm water.
- B. Decrease the volume on the hearing aid.
- C. Clean the hearing aid with isopropyl alcohol.
- D. Turn the hearing aid off for 5 min.
Correct Answer: B
Rationale: Whistling (feedback) often indicates high volume; decreasing it resolves the issue.
A nurse is transferring a client to another unit. Which of the following statements should the nurse include in the transfer report?
- A. His partner has been visiting.
- B. He is voiding adequately.
- C. He is allergic to sulfa.
- D. He appears anxious about the transfer.
Correct Answer: C
Rationale: Allergies (sulfa) are critical clinical data for safe care on the new unit.
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. Don't worry. Everything will work out for you.
- B. Your quality of life will be compromised if you make this decision.
- C. We should talk about your decision later.
- D. How will you discuss this decision with your loved ones?
Correct Answer: D
Rationale: This response supports the client's autonomy and encourages communication.
The nurse is reinforcing discharge teaching with the client and their caregiver. Which of the following information should the nurse include? Select all that apply.
- A. Ensure the oxygen delivery system is at least 8 feet from any heat source
- B. Adjust the oxygen flow rate as needed to ease breathing.
- C. Take antibiotic medication with or without food.
- D. Decrease the steroid dose each day.
- E. Take antibiotics for 10 days.
- F. Store the oxygen cylinder wrench with the oxygen tank.
- G. Take steroid medication in the morning.
Correct Answer: A,E,F,G
Rationale: A: Safety precaution. E: Standard antibiotic duration. F: Accessibility for emergencies. G: Morning steroids reduce adrenal suppression.