Nokea
A nurse is reinforcing teaching with an older adult client who has urinary incontinence. Which of the following instructions should the nurse include?
- A. Drink citrus juice with meals.
- B. Train the bladder by voiding every 5 hr.
- C. Perform pelvic-muscle exercises.
- D. Apply adult diapers at bedtime.
Correct Answer: C
Rationale: Pelvic-muscle exercises (Kegels) strengthen muscles to reduce incontinence.
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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 insurance agency in regard to a life insurance policy
- B. To a family member when the client is not available
- C. To a medical interpreter service on behalf of a client
- D. To an employer for a pre-employment screening
Correct Answer: C
Rationale: Disclosure to an interpreter is allowed to facilitate care, adhering to HIPAA exceptions.
A nurse is caring for a client who is receiving detoxification treatment for an opioid use disorder. As the nurse is preparing to administer a methadone IM injection, the client tells the nurse, 'I am afraid of needles.' Which of the following actions should the nurse take?
- A. Request a change in the medication route to PO.
- B. Remind the client that they must receive the medication as prescribed.
- C. Tell the client not to worry because the pain will be temporary.
- D. Ask one of the client's loved ones to encourage them to receive the IM
Correct Answer: A
Rationale: Requesting a PO route addresses the client's fear while ensuring treatment continuity.
A nurse is reinforcing teaching about end-of-life care with the partner of a client. Which of the following statements should the nurse make?
- A. We will use an electric blanket to keep your partner warm.
- B. Encourage your partner to eat three large meals each day.
- C. Assume your partner can hear you, even if they do not respond.
- D. Opioids will be restricted if your partner develops respiratory distress.
Correct Answer: C
Rationale: Assuming hearing persists respects dignity and encourages communication in end-of-life care.
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 collecting data from a client who has an acute condition. Which of the following findings should the nurse identify as increasing the risk for potential client injuries?
- A. Hearing acuity intact
- B. Oriented to person only
- C. Full range of motion bilateral lower extremities
- D. Ability to use call light
Correct Answer: B
Rationale: Orientation to person only indicates confusion, increasing injury risk.