Nokea
A nurse is providing nonpharmacological interventions for a client who is experiencing pain. Which of the following actions should the nurse take?
- A. Keep the client's room well lit.
- B. Encourage the client to abstain from distracting activities.
- C. Ensure that the client's room is kept at a cool temperature.
- D. Play music in the client's room.
Correct Answer: D
Rationale: Music distracts from pain and promotes relaxation, a nonpharmacological approach.
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A nurse is preparing to insert an indwelling urinary catheter and is verifying the client's express consent for this procedure. Which of the following actions should the nurse take?
- A. Obtain verbal consent from the client.
- B. Have another nurse co-sign the client's consent.
- C. Check the medical record for the client's signature on a previous consent form.
- D. Witness the client's signature on a consent form.
Correct Answer: D
Rationale: Witnessing the signature ensures informed consent for the procedure.
A nurse is showing a newly licensed nurse how to use a mechanical lift. Which of the following statements by the newly licensed nurse indicates an understanding of this assistive device?
- A. The sides of the sling are for the client to hold on to.
- B. This type of device is useful for a client who cannot assist.
- C. The lower end of the sling goes below the client's calves.
- D. The device requires the client to use upper body strength.
Correct Answer: B
Rationale: Mechanical lifts aid clients unable to assist, ensuring safe transfers.
A nurse is collecting data from a client who reports feeling short of breath and notes that the client's SaO2 level is 88% while on room air. Which of the following actions should the nurse take first?
- A. Check the client's medical records to see which medications were recently administered.
- B. Review the client's most recent SaO2 level in the medical record.
- C. Notify the charge nurse of the client's condition.
- D. Recheck the client's SaO2 level after having the client cough and clear their throat.
Correct Answer: D
Rationale: Rechecking after coughing assesses if the low SaO2 is due to mucus, addressing it immediately.
A nurse is participating in a group discussion about complicated grief associated with loss. Which of the following should the nurse identify as an example of exaggerated grief?
- A. A client whose grief response is repressed.
- B. A client whose grief response begins following a terminal diagnosis.
- C. A client whose grief response leads to self-destructive behaviors.
- D. A client whose grief response is triggered by a secondary loss.
Correct Answer: C
Rationale: Exaggerated grief involves intense, harmful reactions like self-destructive behaviors, impairing function.
A nurse on a medical-surgical unit receives a telephone call from an individual who identifies himself as the client's employer. The employer asks the nurse about the client's condition. Which of the following is an appropriate response by the nurse?
- A. The client's condition is stable right now.
- B. I will tell him you called.
- C. I cannot confirm or deny that we have a client by that name.
- D. He is here in the hospital, but I cannot tell you anything else.
Correct Answer: C
Rationale: This response protects confidentiality under HIPAA by not disclosing client presence.