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During the admission process, a client requests more information about advance directives. Which professional should the nurse recommend the client contact?
- A. Family attorney.
- B. Nurse manager.
- C. Hospice nurse.
- D. Chaplain.
Correct Answer: A
Rationale: Attorney provides legal guidance on advance directives.
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While electronically scanning the client's armband at the bedside prior to administering pain medication, the nurse observes the power flickers and the computer screen goes blank. The computer fails to reboot and the screen remains dark. Which action should the nurse do first?
- A. Notify the information services department of the situation.
- B. Print electronic medical record (EMR) from the backup server.
- C. Identify information as a late entry in the record.
- D. Wait for notification that the system has been rebooted.
Correct Answer: A
Rationale: IT notification resolves system issues quickly.
The nurse observes that a client on a clear liquid diet has a cup of coffee on the breakfast tray. Which action should the nurse implement?
- A. Remove the coffee from the tray, advising the client that it is not included in the diet.
- B. Determine which member of the nursing staff brought the cup of coffee to the client.
- C. Remind the client that no milk or creamer can be added to the coffee.
- D. Consult with the dietician to learn if the client is allowed to drink coffee.
Correct Answer: C
Rationale: Black coffee is allowed without additives.
A bedfast female client awakens during the night, reporting to the nurse that she is 'uncomfortable.' What action should the nurse implement first?
- A. Engage the client in relaxation exercises.
- B. Offer to sit with the client until she relaxes.
- C. Administer a prescribed PRN analgesic.
- D. Assist the client to a different position.
Correct Answer: D
Rationale: Repositioning often relieves discomfort.
When turning a male client who has been lying on his back for 2 hours, the nurse notes that the skin over his sacrum is very white. The client is repositioned and when the nurse reassesses the sacrum 2 hours later, the area is bright red. Which intervention should the nurse implement?
- A. Apply a warm compress to the sacral area.
- B. Wash the area with soap and water.
- C. Reassess and turn the client in 30 minutes.
- D. Massage the reddened area with lotion.
Correct Answer: C
Rationale: Frequent turning prevents pressure ulcers by relieving pressure.
During the admission assessment to the hospital, a male client reports that he is allergic to latex, penicillin, and bananas. Which intervention should the nurse implement first?
- A. Send a list of medication allergies to the pharmacy.
- B. Secure an allergy bracelet around the client's wrist.
- C. Notify the dietary department of the client's fruit allergy.
- D. Place a latex-free supply cart outside the client's room.
Correct Answer: B
Rationale: Allergy bracelet ensures immediate awareness.