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. Repeat the test three times using the same stool specimen.
- C. Have the client defecate into a bedpan that contains a small amount of water.
- D. Wear sterile gloves when handling the stool specimen
Correct Answer: A
Rationale: Urine can contaminate the specimen and affect test accuracy.
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A nurse is assisting with scoliosis screenings for students at a public school. Which of the following findings should the nurse recognize as an indication of scoliosis?
- A. Unequal height of the shoulders
- B. Expansion of the upper intercostal spaces
- C. Increased convex curve of the cervical spine
- D. Increased concave curve of the thoracic spine
Correct Answer: A
Rationale: Unequal shoulder height is a classic sign of scoliosis due to spinal curvature.
A nurse is assisting in the care of a client who is receiving newly prescribed IV antibiotics. Which of the following findings should the nurse report immediately?
- A. Small, raised vesicles over the body
- B. Rhinitis
- C. Itching of the skin
- D. Severe wheezing
Correct Answer: D
Rationale: Severe wheezing indicates a possible anaphylactic reaction, requiring immediate reporting.
A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery. The client's BP was 126/72 mm Hg 15 min ago. The nurse now finds that the client's BP is 176/96 mm Hg. Which of the following actions should the nurse take?
- A. Use a narrower cuff to repeat the BP measurement.
- B. Request a prescription for an antihypertensive medication.
- C. Deflate the cuff faster when repeating the BP measurement.
- D. Measure the client's BP in the other arm.
Correct Answer: D
Rationale: Measuring in the other arm verifies the sudden BP increase, ruling out measurement error.
A nurse is reinforcing teaching with a group of newly licensed nurses regarding client confidentiality. In which of the following situations can the nurse disclose health information without the client's written consent?
- A. To an insurance agency in regard to a life insurance policy
- B. To a family member when the client is not available
- C. To a medical interpreter service on behalf of a client
- D. To an employer for a pre-employment screening
Correct Answer: C
Rationale: Disclosure to an interpreter is allowed to facilitate care, adhering to HIPAA exceptions.
A nurse is preparing to reinforce teaching with a client who has expressive aphasia. Which of the following actions should the nurse plan to take?
- A. Avoid the use of facial gestures during the instructions.
- B. Determine the client's ability to use a communication board.
- C. Speak with a loud voice while providing the information.
- D. Provide the teaching without expecting the client to respond.
Correct Answer: B
Rationale: A communication board can aid clients with expressive aphasia in understanding and responding.