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During the admission assessment of a terminally ill male client, he states that he is an agnostic. What is the best nursing action in response to this statement?
- A. Provide information about the hours and location of the chapel
- B. Document the statement in the client's spiritual assessment
- C. Invite the client to a healing service for people of all religions
- D. Offer to contact a spiritual advisor of the client's choice
Correct Answer: B
Rationale: Documenting the client's statement in the spiritual assessment is the best nursing action in response to his disclosure of being an agnostic. This respects the client's beliefs and preferences, ensuring that care is tailored to his individual needs. It also demonstrates a commitment to providing holistic and patient-centered care.
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The healthcare provider is caring for a client who is experiencing fluid volume deficit (dehydration). Which intervention should the healthcare provider implement to assess the effectiveness of fluid replacement therapy?
- A. Monitor daily weights
- B. Assess skin turgor
- C. Evaluate blood pressure trends
- D. Check urine specific gravity
Correct Answer: A
Rationale: Monitoring daily weights is an accurate method to assess the effectiveness of fluid replacement therapy because changes in weight reflect changes in fluid balance. Fluid volume deficit can be objectively evaluated by monitoring daily weights as it provides a more precise measurement of fluid status over time.
During the digital removal of a fecal impaction, the nurse should stop the procedure and take corrective action if which client reaction is noted?
- A. Temperature increases from 98.8° to 99.0° F.
- B. Pulse rate decreases from 78 to 52 beats/min.
- C. Respiratory rate increases from 16 to 24 breaths/min.
- D. Blood pressure increases from 110/84 to 118/88 mmHg.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with a diagnosis of chronic obstructive pulmonary disease (COPD) is receiving oxygen via nasal cannula at 4 liters per minute. Which assessment finding indicates a need for immediate action?
- A. The client's respiratory rate is 14 breaths per minute.
- B. The client's oxygen saturation is 92%.
- C. The client reports shortness of breath.
- D. The client's respiratory rate is 24 breaths per minute.
Correct Answer: C
Rationale: A report of shortness of breath (C) indicates that the client is not tolerating the oxygen therapy well and may need an adjustment. Shortness of breath is a critical symptom in a client with COPD, as it signifies potential respiratory distress. A respiratory rate of 14 (A), oxygen saturation of 92% (B), and respiratory rate of 24 (D) are not as immediately concerning as they may still fall within acceptable ranges for a client with COPD.
The healthcare professional is assessing a client with a diagnosis of peripheral arterial disease (PAD). Which assessment finding is most indicative of this condition?
- A. Dependent rubor.
- B. Absence of hair on the lower legs.
- C. Shiny, thin skin on the legs.
- D. Pain in the legs when walking.
Correct Answer: D
Rationale: Pain in the legs when walking (D), known as intermittent claudication, is most indicative of peripheral arterial disease (PAD). While dependent rubor (A), absence of hair (B), and shiny, thin skin (C) are also associated with PAD, they are less specific than intermittent claudication. Intermittent claudication is a hallmark symptom of PAD caused by inadequate blood flow to the legs during exercise, resulting in pain that resolves with rest.
What action should the nurse implement to prepare a client for the potential side effects of a newly prescribed medication?
- A. Assess the client for health alterations that may be impacted by the effects of the medication
- B. Teach the client how to administer the medication to promote the best absorption
- C. Administer a half dose and observe the client for side effects before administering a full dosage
- D. Encourage the client to drink plenty of fluids to promote effective drug distribution
Correct Answer: A
Rationale: Before initiating a new medication, the nurse should conduct a thorough assessment of the client to identify any pre-existing health conditions or risk factors that could be affected by the medication. This assessment helps in establishing a baseline for monitoring potential side effects and determining the medication's appropriateness for the client.