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A nurse is reinforcing teaching about advance directives with a client who has terminal colorectal cancer. Which of the following statements by the client indicates an understanding of the teaching?
- A. I'm glad to have the opportunity to choose what kind of care I receive while I still can.
- B. I can't change my mind about the care I will receive once I sign my living will.
- C. Once I fill out my living will, there will be a 1-month delay before it is legally binding.
- D. If I want life support, I'll need to sign a separate consent form first.
Correct Answer: A
Rationale: This reflects understanding that advance directives allow care choices while capable.
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A nurse is reinforcing teaching with a client about blood glucose monitoring. The client becomes quiet and appears distracted while the nurse is providing the instructions. Which of the following responses should the nurse make?
- A. Let's talk about what you're thinking.
- B. Is this something you think you can do?
- C. Are you feeling okay?
- D. Do you need more time to absorb this information?
Correct Answer: A
Rationale: Engaging the client about their thoughts addresses distraction and builds rapport.
A nurse is caring for a postoperative male client in the surgical unit. Click to highlight the documentation in the client's medical record that requires further action by the nurse. Select all that apply
- A. Respiratory rate 10/min
- B. Pulse oximetry 88% on room air
- C. Blood pressure 99/46 mm Hg
- D. Morphine 10 mg administered subcutaneously
Correct Answer: A,B,D
Rationale: A: Low respiratory rate suggests opioid depression. B: Low SaO2 indicates hypoxemia. D: Morphine dose may need reassessment due to side effects.
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. Increased concave curve of the thoracic spine.
- C. Expansion of the upper intercostal spaces.
- D. Increased convex curve of the cervical spine.
Correct Answer: A
Rationale: Unequal shoulder height is a classic sign of scoliosis due to lateral spinal curvature.
A nurse is collecting data from a client who has diabetes mellitus. The nurse should ask which of the following to determine the client's ability to provide foot self-hygiene?
- A. Do you have any problems taking care of your feet?
- B. Do you go barefoot at home?
- C. Have you noticed any problems with foot swelling?
- D. Have you had a problem with ingrown toenails?
Correct Answer: A
Rationale: This directly assesses ability to perform foot care, critical for diabetes management.
A nurse is recording the intake and output (I&O) for a client. The client consumed 8 oz of milk, 10 oz of water, 4 oz of gelatin, 1 egg, 1 piece of bacon, and 2 biscuits. Which volume should the nurse record on the I&O?
Correct Answer: 660 mL
Rationale: 8 oz milk (240 mL) + 10 oz water (300 mL) + 4 oz gelatin (120 mL) = 660 mL; only liquids are recorded.