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A nurse is providing care to a client who is preparing to undergo surgery. The client inquires about advance directives. Which of the following statements should the nurse make?
- A. Advance directives are the same as a consent form for health care treatment.
- B. Advance directives protect your right to make your own health care decisions.
- C. Advance directives must be approved by your lawyer.
- D. Advance directives are for clients who have life-threatening conditions.
Correct Answer: B
Rationale: Advance directives ensure client autonomy in health care decisions.
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A nurse is reinforcing teaching with a client who has a new prescription for epinephrine auto-injector PRN. The nurse should reinforce with the client that the medication can help treat which of the following manifestations?
- A. Hand tremors
- B. Shortness of breath
- C. Nausea
- D. Hyperglycemia
Correct Answer: B
Rationale: Epinephrine treats shortness of breath in anaphylaxis.
An assistive personnel reports that the client has a blood pressure of 190/110 mm Hg.
A nurse is collecting data from a client who has chronic kidney failure. An assistive personnel reports that the client has a blood pressure of 190/110 mm Hg. Which of the following actions should the nurse take first?
- A. Remeasure the client's blood pressure.
- B. Administer an antihypertensive medication.
- C. Report the blood pressure reading to the charge nurse.
- D. Instruct the client to remain in bed.
Correct Answer: A
Rationale: Remeasuring verifies the accuracy of the elevated reading before further action.
The client becomes combative and threatens other clients and staff.
A nurse is working with a client who becomes combative and threatens other clients and staff. Which of the following actions should the nurse take?
- A. Stand in front of the client to block them from others in the room.
- B. Apply restraints according to the facility's standing order.
- C. Ensure there are enough staff members available for assistance.
- D. Obtain a PRN prescription for restraints from the provider.
Correct Answer: C
Rationale: Ensuring staff availability ensures safety without immediate restraint use.
A nurse is contributing to the plan of care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include?
- A. Monitor the client for 1 hr after meals.
- B. Weigh the client every 2 days.
- C. Check the client's vital signs two times per week.
- D. Allow the client 2 hr to finish meals.
Correct Answer: A
Rationale: Monitoring for 1 hour after meals prevents purging, a key intervention for anorexia.
A nurse in an acute care setting is assisting in collecting client information to include in a referral for a physical therapist. Which of the following information should the nurse plan to include?
- A. Family medical history
- B. Medications taken prior to admission
- C. Physical assessment findings
- D. Medical health insurance claim
Correct Answer: C
Rationale: Physical assessment findings inform the therapist's treatment plan.