Nokea
A nurse is preparing to perform a fecal occult blood test of stool specimens for a client. Which of the following actions should the nurse plan to take?
- A. Ensure that the stool specimen does not contain urine.
- B. Wear sterile gloves when handling the stool specimen.
- C. Repeat the test three times using the same stool specimen.
- D. Have the client defecate into a bedpan that contains a small amount of water.
Correct Answer: A
Rationale: Urine contamination can cause false positives, compromising test accuracy.
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A nurse is collecting data from a client who has a BMI of 29. The nurse should document that the client is in which of the following weight categories?
- A. Overweight
- B. Ideal body weight
- C. Obese
- D. Underweight
Correct Answer: A
Rationale: A BMI of 29 falls in the overweight range (25-29.9), per standard classifications.
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. Room number
- B. Medical diagnosis
- C. Age
- D. Photograph
Correct Answer: D
Rationale: A photograph provides a unique, visual confirmation of identity for safe medication administration.
A nurse is caring for a client who refuses their morning dose of antihypertensive medication. The client tells the nurse, 'I'm not going to take this medication because it makes me sick and dizzy.' Which of the following actions should the nurse take first?
- A. Notify the provider of the client's refusal.
- B. Document the refusal in the client's medical record.
- C. Inform the client of the potential consequences of their refusal.
- D. Return the medication to the medication cabinet.
Correct Answer: C
Rationale: Informing about consequences first educates the client, supporting informed decision-making.
A nurse is assisting in the care of a client who just started receiving a blood transfusion 5 min ago. Which of the following findings should be reported first to the provider?
- A. Headache
- B. Dyspnea
- C. Hyperthermia
- D. Urticaria
Correct Answer: B
Rationale: Dyspnea may indicate a severe transfusion reaction like TRALI, requiring urgent reporting.
A nurse is reinforcing teaching with a client about the use of a quad cane. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should wear shoes with smooth soles to help slide my weak leg forward.
- B. I will move the cane forward 18 inches.
- C. I will hold the cane on my stronger side.
- D. I should move my stronger leg forward before moving my weaker leg.
Correct Answer: C
Rationale: Holding the cane on the stronger side enhances stability and support for the weaker side.