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A nurse on a medical-surgical unit is caring for a postoperative client who reports difficulty sleeping due to noise. Which of the following interventions is appropriate for the nurse to implement?
- A. Conduct staff communications away from the client's room.
- B. Turn off alarms on bedside monitoring equipment.
- C. Avoid entering the client's room unless requested during the night.
- D. Turn on the client's TV to distract from hallway noise.
Correct Answer: A
Rationale: Reducing noise by moving staff communication away enhances sleep without compromising safety.
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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. Place 1.3 cm (0.5 in) of formed stool into a culture tube.
- B. Keep the specimen in a warm area.
- C. Avoid placing toilet tissue in the bedpan after defecation.
- D. Urinate after the specimen collection.
Correct Answer: C
Rationale: Avoiding toilet tissue prevents contamination of the stool specimen with fibers or chemicals.
A nurse is preparing to reinforce teaching with a client who has expressive aphasia. Which of the following actions should the nurse plan to take?
- A. Provide the teaching without expecting the client to respond.
- B. Determine the client's ability to use a communication board.
- C. Speak with a loud voice while providing the information.
- D. Avoid the use of facial gestures during the instructions.
Correct Answer: B
Rationale: A communication board aids clients with expressive aphasia in responding, enhancing understanding.
A nurse is collecting data from a client about bowel elimination. Which of the following statements by the client indicates a risk for impaired bowel elimination?
- A. I drink two hot cups of coffee each morning.
- B. I love to eat apples and black-eyed peas.
- C. I take a prescribed opioid pain medication at bedtime.
- D. I drink an average of 2,000 milliliters of water daily.
Correct Answer: C
Rationale: Opioids slow gastrointestinal motility, increasing the risk of constipation and impaired bowel elimination.
A nurse is collecting data from a client who has a BMI of 29. The nurse should document that the client is in which of the following weight categories?
- A. Obese
- B. Underweight
- C. Ideal body weight
- D. Overweight
Correct Answer: D
Rationale: A BMI of 25-29.9 is classified as overweight; 30+ is obese.
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. Return the medication to the medication cabinet.
- B. Notify the provider of the client's refusal.
- C. Inform the client of the potential consequences of their refusal.
- D. Document the refusal in the client's medical record.
Correct Answer: C
Rationale: Educating about consequences first respects autonomy and may encourage compliance.