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A nurse is transferring a client to another unit. Which of the following statements should the nurse include in the transfer report?
- A. He appears anxious about the transfer.
- B. His partner has been visiting.
- C. He is voiding adequately.
- D. He is allergic to sulfa.
Correct Answer: D
Rationale: Allergy information is critical to prevent adverse reactions during care.
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A nurse is delegating client care to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?
- A. Administering vaginal cream to a client who has a vaginal infection.
- B. Providing postmortem care for a client who has just died.
- C. Suctioning a tracheostomy for a client who has a recent head injury.
- D. Changing a peripheral IV dressing for a client who is postoperative.
Correct Answer: B
Rationale: Postmortem care is within the AP’s scope, involving basic care tasks.
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. Place a thick layer of stool on the specimen card.
- B. Urinate prior to collecting the stool specimen.
- C. Discontinue supplements containing vitamin C 24 hours before the test.
- D. Refrain from consuming pork 7 days before the test.
Correct Answer: C
Rationale: Vitamin C can cause false negatives, so discontinuing it ensures accuracy.
A nurse is assisting with the care of a male client in the unit. Complete the following sentence by using the list of options. The client is at risk for developing ___ due to ___.
- A. Aspiration pneumonia
- B. Coughing when eating
- C. sweating
- D. increased heart beat
Correct Answer: A,B
Rationale: A: Coughing during eating increases aspiration risk. B: Indicates potential airway entry.
A nurse is caring for a client who refuses their morning dose of antihypertensive medication. The client tells the nurse, 'I'm not going to take this medication because it makes me sick and dizzy.' Which of the following actions should the nurse take first?
- A. Document the refusal in the client's medical record.
- B. Return the medication to the medication cabinet.
- C. Inform the client of the potential consequences of their refusal.
- D. Notify the provider of the client's refusal.
Correct Answer: C
Rationale: Informing about consequences first respects autonomy and may encourage compliance.
A nurse is reinforcing teaching with a client about how to collect a stool specimen. Which of the following instructions should the nurse include?
- A. Avoid placing toilet tissue in the bedpan after defecation.
- B. Urinate after the specimen collection.
- C. Place 1.3 cm (0.5 in) of formed stool into a culture tube.
- D. Keep the specimen in a warm area.
Correct Answer: A
Rationale: Avoiding toilet tissue prevents contamination, ensuring specimen integrity.