Nokea
A nurse on a medical-surgical unit receives a telephone call from an individual who identifies himself as the client's employer. The employer asks the nurse about the client's condition. Which of the following is an appropriate response by the nurse?
- A. He is here in the hospital, but I cannot tell you anything else.
- B. I cannot confirm or deny that we have a client by that name.
- C. The client's condition is stable right now.
- D. I will tell him you called.
Correct Answer: B
Rationale: Protecting confidentiality under HIPAA requires not confirming client presence.
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A nurse is caring for a client who is postoperative and is preparing to walk for the first time in several days. Which of the following instructions should the nurse give the client to prevent orthostatic hypotension?
- A. Use your incentive spirometer.
- B. Dangle your legs over the side of the bed.
- C. Increase your intake of protein.
- D. Perform regular isometric exercises.
Correct Answer: B
Rationale: Dangling legs helps acclimate the body to positional changes, reducing hypotension risk.
A nurse is preparing to remove an NG tube for a client who is postoperative following colon surgery. In which order should the nurse perform the following steps? (Move the steps, placing them in the order of performance. Use all the steps.)
- A. Pinch and withdraw the tube.
- B. Disconnect the tube from the suction device.
- C. Instill 50 mL of air into the tube.
- D. Ask the client to take a deep breath.
- E. Apply clean gloves.
Correct Answer: E,B,C,D,A
Rationale: E: Gloves first. B: Disconnect suction. C: Instill air clears tube. D: Deep breath aids removal. A: Pinch and withdraw.
A nurse is caring for a young adult client who is postoperative and requires physical therapy, pain management, and dietary advancement. The nurse enters the client's room and finds them dressing and stating that they are going home. Which of the following actions should the nurse take?
- A. Administer a sedative medication to the client.
- B. Have the client sign an against medical advice form.
- C. Tell the client that the surgeon will prescribe restraints if they try to leave.
- D. Explain to the client that they cannot leave until the surgeon discharges them.
Correct Answer: B
Rationale: An AMA form documents the client's informed decision to leave against advice.
A nurse is caring for an older adult client who has fecal incontinence. Which of the following actions should the nurse take?
- A. Apply cornstarch powder to the perineal area.
- B. Place a moisture barrier ointment over the perineal area.
- C. Turn the client every 4 hr.
- D. Cleanse the perineal area with povidone-iodine solution.
Correct Answer: B
Rationale: Moisture barrier ointment protects skin from breakdown due to incontinence.
A nurse is reinforcing discharge teaching with a male client who has an indwelling urinary catheter. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will clamp the tube when I go for a walk.
- B. I will keep the drainage bag below the level of my waist.
- C. I will empty my drainage bag once a day.
- D. I will apply antiseptic ointment to the tip of my penis.
Correct Answer: B
Rationale: Keeping the bag below the waist prevents urine backflow and infection.