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While the nurse is administering medications to a client, the client states 'I do not want to take that medicine today.' Which of the following responses by the nurse would be best?
- A. That's OK, its all right to skip your medication now and then.'
- B. I will have to call your doctor and report this.'
- C. Is there a reason why you don't want to take your medicine?'
- D. Do you understand the consequences of refusing your prescribed treatment?'
Correct Answer: C
Rationale: When a new problem is identified, it is important for the nurse to collect accurate assessment data. This is crucial to ensure that client needs are adequately identified in order to select the best nursing care approaches. The nurse should try to discover the reason for the refusal which may be that the client has developed untoward side effects.
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The nurse is caring for clients in a hospital setting. Which observations made by the nurse require intervention? Select all that apply.
- A. The client's infusion pump is noted to have a cut in the center of the cord.
- B. The client's bed is in the high position after a nursing assistant left the room.
- C. The client's battery-operated CD player does not have an agency inspection tag.
- D. The client's bed exit alarm is beeping, and another nurse just left the room.
- E. The client's bedside table is placed in front of the chair where the client is sitting.
Correct Answer: A,B,D
Rationale: A: A cut cord poses an electrical shock risk. B: A high bed increases fall risk. D: A beeping bed exit alarm indicates a potential fall risk requiring immediate response.
The client makes the following statements to the home health nurse. Which statement requires the nurse to intervene immediately?
- A. "I can't lift pans from the back burners, but I can manage just fine by using the front burners of my stove."
- B. "I almost fell down the stairs, so I bought myself a pair of slippers with nonskid soles."
- C. "The grass near the sidewalk will be dead because my son insists on putting salt on the icy sidewalk."
- D. "My home is less costly to heat when I use my gas oven with the oven door open to heat just my living areas."
Correct Answer: D
Rationale: Using a gas oven for heating risks carbon monoxide poisoning, requiring immediate intervention to prevent a life-threatening situation.
The hospitalized client states, "I can't wait for anyone to take me to the bathroom, or I will wet my pants." What should the nurse do? Select all that apply.
- A. Assess the client's risk for a fall using a rating scale.
- B. Document that the client is frequently incontinent.
- C. Ensure an immediate response to the client's call light.
- D. Educate the client regarding fall prevention strategies.
- E. Place a note on the door stating, "bathroom every two hours."
- F. Request that the HCP prescribe placement of a urinary catheter.
Correct Answer: A,C,D
Rationale: A: Assessing fall risk is essential due to urgency. C: Prompt response to call light prevents rushing. D: Education on fall prevention is proactive. B is incorrect as incontinence cannot be assumed. E violates privacy. F is unnecessary and risky.
The nurse has been teaching adult clients about cardiac risks when they visit the hypertension clinic. Which evaluation data would best measure learning?
- A. Performance on written tests
- B. Responses to verbal questions
- C. Completion of a mailed survey
- D. Reported behavioral changes
Correct Answer: D
Rationale: Reported behavioral changes. If the client alters behaviors such as smoking, drinking alcohol, and stress management, these suggest that learning has occurred. Additionally, physical assessments and lab data may confirm risk reduction.
A thirty-seven year-old female in room 307 has a diagnosis of acquired immune deficiency syndrome (AIDS). Which of the following situations requires nurse intervention?
- A. A certified nursing assistant states, 'The patient in 307 is not wearing gloves shaving her legs.'
- B. A nursing assistant at the nursing station states, 'The patient in 307 has a respiratory rate of 16.'
- C. A nursing student in the cafeteria states, 'Dr. Jones told the patient in room 307 that she was going to die.'
- D. A certified nursing assistant states, 'Dr. Jones hasn't made rounds this morning.'
Correct Answer: C
Rationale: Patient confidentiality should be observed, especially in public places. The nurse should tell the nursing student do not discuss confidential information in public.