Nokea
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. Aren't you interested in learning how to perform this test?
- B. Let's talk about what you're thinking.
- C. I'll discuss this with your partner instead.
- D. Is this something you think you can do?
Correct Answer: B
Rationale: Exploring the client's thoughts addresses distractions and improves teaching effectiveness.
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A nurse is planning to provide postmortem care for a client who requires an autopsy. Which of the following actions should the nurse plan to take?
- A. Place an identification tag on the outside of the client's shroud.
- B. Remove the client's dentures and give them to the client's family.
- C. Wear sterile gloves when cleaning the client's body.
- D. Ask the assistive personnel to document the client's time of death.
Correct Answer: A
Rationale: An ID tag on the shroud ensures proper identification for autopsy purposes.
A nurse is reviewing the laboratory results for a client who reports vomiting and diarrhea for 2 days, which of the following laboratory findings should the nurse expect?
- A. Hypocalcemia
- B. Hypermagnesemia
- C. Hyperkalemia
- D. Hypokalemia
Correct Answer: D
Rationale: Vomiting and diarrhea cause potassium loss, leading to hypokalemia.
A nurse is reinforcing discharge teaching about fecal occult blood testing with a client. Which of the following instructions should the nurse include in the teaching?
- A. Discontinue supplements containing vitamin C 24 hr before the test.
- B. Refrain from consuming pork 7 days before the test.
- C. Place a thick layer of stool on the specimen card.
- D. Urinate prior to collecting the stool specimen.
Correct Answer: D
Rationale: Urinating first prevents urine contamination of the stool specimen.
A nurse is reinforcing teaching with a client who has an ostomy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will clean around the stoma with a moisturizing soap.
- B. I will press on the skin barrier for 30 seconds to ensure that it adheres.
- C. I will cut an opening in the skin barrier that is 1/2 inch larger than the stoma.
- D. I will apply a thin layer of talc powder around the stoma before placing the appliance.
Correct Answer: B
Rationale: Pressing the barrier ensures a secure seal, preventing leaks.
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 an employer for a pre-employment screening
- B. To an insurance agency in regard to a life insurance policy
- C. To a family member when the client is not available
- D. To a medical interpreter service on behalf of a client
Correct Answer: D
Rationale: Disclosure to an interpreter is permitted under HIPAA to facilitate care.