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A nurse is reinforcing teaching with a client about advance directives. Which of the following client statements indicates an understanding of the teaching?
- A. A family member will need to witness my signature on my living will.
- B. I need to create advance directives so that I can donate my organs.
- C. I can name my sibling as my designee in my durable power of attorney for health care.
- D. My advance directives can be enforced once my attorney approves them.
Correct Answer: C
Rationale: Naming a sibling as a designee in a durable power of attorney reflects understanding of advance directives.
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A nurse is reinforcing teaching with a client who is perimenopausal. Which of the following statements by the client indicates an understanding of the teaching?
- A. The best time to perform a breast self-examination is on the first day of my period.
- B. I can expect to have regular periods until I am in menopause.
- C. I might have headaches due to a decline in my estrogen levels.
- D. I should stop receiving Papanicolaou tests once I reach menopause.
Correct Answer: C
Rationale: Declining estrogen levels during perimenopause can cause headaches.
A nurse is caring for a client who is confused and has a prescription for wrist restraints. Which of the following actions should the nurse take?
- A. Request a prescription renewal from the provider every 36 hr.
- B. Make sure two fingers fit under the restraints.
- C. Check the client's range of motion every 6 hr.
- D. Secure the restraints with a square knot.
Correct Answer: B
Rationale: Two fingers ensure the restraints are secure but not too tight.
A nurse is preparing to administer ampicillin to a school-age child who weighs 55 lb. The provider prescribes 50 mg/kg/day in 4 equal doses. Available is ampicillin oral suspension 125 mg/5 mL. How many mL should the nurse administer with each dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 12.5 mL
Rationale: 55 lb = 25 kg; 50 mg/kg/day = 1250 mg/day; 1250 mg / 4 doses = 312.5 mg/dose; 312.5 mg / (125 mg/5 mL) = 12.5 mL/dose.
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 a medical interpreter service on behalf of a client
- B. To a family member when the client is not available
- C. To an employer for a pre-employment screening
- D. To an insurance agency in regard to a life insurance policy
Correct Answer: A
Rationale: Disclosure to an interpreter is permissible under HIPAA to facilitate care.
A nurse is caring for a client who has insomnia. Which of the following actions should the nurse take?
- A. Provide the client with snug-fitting nightwear.
- B. Keep the door to the client's room closed.
- C. Administer prescribed diuretics in the evening.
- D. Use overhead lighting when checking equipment.
Correct Answer: B
Rationale: A closed door minimizes disturbances, promoting sleep.