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The healthcare provider prescribes a 24-hour urine specimen to be collected for creatinine clearance. The client is eager to go home and tells the nurse that the first sample was put in the urinal 2 hours ago. Which action should the nurse implement?
- A. Begin the collection the next day.
- B. Empty the sample into the 24-hour container.
- C. Observe the sample for sediment.
- D. Start collecting the specimen with the next void.
Correct Answer: D
Rationale: First void is discarded for accuracy.
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The nurse assesses an older adult client’s ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that the client’s posture is upright, and the gait is smooth and steady. Which action should the nurse take next?
- A. Determine the client’s activity tolerance.
- B. Teach the client to shorten the stride to prevent falls.
- C. Initiate a fall risk protocol for the client.
- D. Record the client’s ability to perform ADLs safely.
Correct Answer: D
Rationale: Documentation reflects functional status.
The nurse is viewing the admission assessment of a client with chronic pain. What intervention(s) should the nurse include in the client’s plan of care? Select all that apply.
- A. Encourage increased fluid intake and measure urinary output every 8 hours.
- B. Provide comfort measures such as topical warm application and tactile massage.
- C. Determine client’s objective measure of pain using a numerical pain scale.
- D. Assist the client to ambulate as much as possible during waking hours.
- E. Implement a 24-hour schedule of routine administration of prescribed analgesics.
Correct Answer: B,C,E
Rationale: Comfort, assessment, and analgesics manage pain.
What times should the nurse measure vital signs? Select all that apply.
- A. 1500
- B. 1600
- C. 1800
- D. 1000
- E. 1200
Correct Answer: A,B,C,D,E,F,G
Rationale: Context-dependent; typically every 4 hours.
The nurse is teaching a client about a newly prescribed medication. To confirm that the client is learning the critical information, which strategy is most important for the nurse to include during the instruction?
- A. Provide client-focused information.
- B. Observe the client’s body language.
- C. Ask the client for learning feedback.
- D. Reinforce key points with the client.
Correct Answer: C
Rationale: Feedback confirms understanding.
The nurse in a skilled nursing facility observes a colleague leaving printed electronic medical record (EMR) copies of a client unattended on a countertop. Which action should the nurse implement?
- A. Send an email to facility administrators reporting the action.
- B. Dispose of the copies and continue with client care assignments.
- C. Warn the colleague that copying health information is unlawful.
- D. Communicate the colleague’s activities to the unit charge nurse.
Correct Answer: D
Rationale: Reporting ensures intervention.