Nokea
A nurse is reinforcing teaching with a client about advance directives. Which of the following client statements indicates an understanding of the teaching?
- A. I can name my sibling as my designee in my durable power of attorney for health care.
- B. I need to create advance directives so that I can donate my organs.
- C. My advance directives can be enforced once my attorney approves them.
- D. A family member will need to witness my signature on my living will.
Correct Answer: A
Rationale: Naming a sibling as a designee is a correct use of a durable power of attorney for health care.
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A nurse is performing a wound irrigation for a client who has methicillin-resistant Staphylococcus aureus. When removing personal protective equipment, which of the following pieces should the nurse remove first?
- A. Mask
- B. Gown
- C. Goggles
- D. Gloves
Correct Answer: D
Rationale: Gloves are removed first as they are most contaminated, preventing pathogen spread.
A nurse is reinforcing a teaching plan regarding proper lifting with a client. Which of the following strategies should the nurse include to prevent back injury when lifting an object?
- A. Keep legs straight.
- B. Bend at the waist.
- C. Tighten the abdominal muscles.
- D. Hold object away from the body.
Correct Answer: C
Rationale: Tightening abdominal muscles stabilizes the spine, reducing back injury risk during lifting.
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. I might have headaches due to a decline in my estrogen levels.
- B. I can expect to have regular periods until I am in menopause.
- C. The best time to perform a breast self-examination is on the first day of my period.
- D. I should stop receiving Papanicolaou tests once I reach menopause.
Correct Answer: A
Rationale: Declining estrogen in perimenopause can cause headaches, reflecting hormonal changes.
A nurse is caring for a client who has insomnia. Which of the following actions should the nurse take?
- A. Administer prescribed diuretics in the evening
- B. Provide the client with snug-fitting nightwear
- C. Keep the door to the client's room closed
- D. Use overhead lighting when checking equipment
Correct Answer: C
Rationale: Closing the door reduces noise, promoting sleep; other options may disrupt it.
A charge nurse on a long-term care unit is working with an assistive personnel who states, 'I am tired of all the changes on this unit. If things don't improve soon, I'm requesting a transfer.' Which of the following responses should the charge nurse make?
- A. Why don't you just file a formal complaint with Human Resources?
- B. Please, try to wait a little longer. Things will get better soon.
- C. There has been too much complaining about these changes.
- D. So, you are upset about all of the recent changes on the unit?
Correct Answer: D
Rationale: Reflecting the AP's feelings fosters communication and addresses concerns constructively.