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A nurse is reinforcing teaching about the side effects of metoprolol. Which of the following client statements indicates an understanding of the teaching?
- A. I need to be careful when standing up from bed.
- B. I should limit my intake of leafy green vegetables.
- C. I should expect some weight loss.
- D. I may experience loss of taste.
Correct Answer: A
Rationale: Metoprolol can cause orthostatic hypotension, requiring caution when standing.
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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.
A nurse on a mental health unit is caring for a client who is in restraints. Which of the following actions should the nurse take?
- A. Release the client's restraints every 4 hr.
- B. Check the client's status every hour.
- C. Obtain written consent by the client for the placement of the restraints.
- D. Document the client's behavior leading to the initiation of the restraints.
Correct Answer: D
Rationale: Documenting behavior justifies restraint use and meets legal standards.
A nurse is receiving a telephone prescription from a client's provider. Which of the following actions should the nurse take? (Select all that apply)
- A. Instruct another nurse to record the prescription in the medical record.
- B. Ask the provider to spell out the name of the medication.
- C. Withhold the medication until the provider signs the prescription.
- D. Record the date and time of the telephone prescription.
- E. Request that the provider confirm the read-back of the prescription.
Correct Answer: B,D,E
Rationale: Spelling the medication, recording date/time, and confirming read-back ensure accuracy and safety.
A nurse is providing site care for a child who has a gastrostomy enteral tube. Which of the following actions should the nurse take?
- A. Tape the tube to the child's cheek.
- B. Attach an extension tube to the site's opening prior to use.
- C. Secure the tubing to the child's abdomen.
- D. Apply water-soluble lubricant to the site.
Correct Answer: C
Rationale: Securing the tube to the abdomen prevents dislodgement.
A nurse is reinforcing teaching about circumcision care with the parent of an infant who just underwent a Plastibell circumcision. Which of the following statements by the parent indicates an understanding of the teaching?
- A. I will wipe away yellow crusts that form around the incision.
- B. I will make sure that my baby's diaper is applied snugly.
- C. I will apply pressure with gauze if I see bleeding.
- D. I will apply antibiotic ointment to my baby's penis.
Correct Answer: C
Rationale: Applying pressure with gauze controls bleeding, a key aspect of Plastibell circumcision care.