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The nurse is caring for a client who had a surgical excision and biopsy of a tumor. The biopsy results show that the tumor is malignant, but the client has not yet been informed by the health care provider. The client asks the nurse, 'Am I going to die?' Which of the following responses would be appropriate for the nurse to make?
- A. You seem upset. Tell me more about how you are feeling about this situation.
- B. I understand that you feel anxious. Maybe watching television will help you relax.
- C. Waiting for test results can be very stressful. I am sure that it will all work out.
- D. The biopsy results show that you have cancer. However, many cancers are treatable.
Correct Answer: A
Rationale: Exploring the client's feelings is supportive and appropriate, as the nurse should not disclose results before the provider.
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The nurse at an orthopedic joint clinic is assisting with the preparation of pre-operative teaching for clients scheduled for total hip replacement surgery. Which would be included in the teaching plan?
- A. Avoid sitting in a recliner
- B. Make sure that commode seats are at low levels
- C. Avoid crossing the legs when sitting
- D. Physical therapy will assist with adduction leg exercises
Correct Answer: C
Rationale: The client with joint hip replacement should avoid adduction of the legs and flexion of the hips greater than 90 degrees to ensure continued placement of the prosthetic joint. It is recommended for these clients to use recliners for seating instead of straight chairs, therefore A is incorrect. Commode seats will have to be raised and abduction of the legs is required, making B and D incorrect choices.
The nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? Select all that apply.
- A. Prepare to suction the client.
- B. Turn the client to a side-lying position.
- C. Restrain the client's upper extremities.
- D. Request assistance from other staff members.
- E. Use a tongue blade to depress the client's tongue.
Correct Answer: A,B,D
Rationale: Suctioning, side-lying position, and assistance protect the client. Restraining or using a tongue blade can cause injury.
The licensed vocational nurse cannot assume the primary care for a client:
- A. In the fourth stage of labor
- B. Two days post appendectomy
- C. With a venous access device
- D. With bipolar disorder
Correct Answer: A
Rationale: The fourth stage of labor requires advanced nursing skills due to potential complications, unsuitable for an LVN's primary role. Post-appendectomy , venous access , and bipolar disorder are within LVN scope.
The nurse is caring for a 75 year old client in congestive heart failure. Which finding suggests that digitalis levels should be reviewed?
- A. Extreme fatigue
- B. Increased appetite
- C. Intense itching
- D. Constipation
Correct Answer: A
Rationale: Extreme fatigue. Extreme fatigue and weakness are common, early signs of digitalis toxicity, which would be confirmed by a high blood serum level of digitalis.
The 11:00 AM routine fingerstick (glucose monitoring) test for a client was assigned to the unlicensed assistive personnel by the nurse. At 11:15 AM, the client tells the nurse that no one checked the blood level. The nurse should take what action first?
- A. Ask the unlicensed assistive personnel (UAP) about the situation
- B. Inform the nurse manager
- C. Perform the test
- D. Review the fingerstick procedure with the UAP
Correct Answer: C
Rationale: Performing the test ensures timely glucose monitoring, which is critical for the client's care.