Nokea
A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, 'What would happen if I arrived at the emergency department and I had difficulty breathing?' Which of the following responses should the nurse make?
- A. We would consult the person appointed by your health care proxy to make decisions.
- B. We would give you oxygen through a tube in your nose.
- C. You would be unable to change your previous wishes about your care.
- D. We would insert a breathing tube while we evaluate your condition.
Correct Answer: A
Rationale: The correct answer is A: We would consult the person appointed by your health care proxy to make decisions. This response aligns with the client's living will and respects their wishes for declining resuscitation. By involving the designated health care proxy, the healthcare team ensures that decisions are made in accordance with the client's preferences.
Choice B is incorrect because providing oxygen through a tube does not address the client's concerns about declining resuscitation. Choice C is incorrect as it does not address the client's current situation or need for support in the emergency department. Choice D is incorrect as it goes against the client's expressed wishes in the living will. It is important to prioritize the client's autonomy and respect their decisions regarding end-of-life care.
You may also like to solve these questions
A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching?
- A. Remove the outer cannula carefully during cleaning.
- B. Use tracheostomy covers when outdoors.
- C. Use sterile technique when performing tracheostomy care at home.
- D. Cleanse mist with full-strength hydrogen peroxide.
Correct Answer: C
Rationale: The correct answer is C: Use sterile technique when performing tracheostomy care at home. This is crucial to prevent infections and ensure the client's safety. Sterile technique involves maintaining a clean environment, using sterile gloves, and sterile supplies to reduce the risk of introducing harmful microorganisms. Removing the outer cannula during cleaning (A) can increase the risk of accidental dislodgement and should only be done when necessary by a healthcare professional. Tracheostomy covers (B) are used to provide warmth and moisture, not necessarily for infection control. Cleansing mist with full-strength hydrogen peroxide (D) is too harsh and can damage the skin and mucous membranes.
A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use?
- A. The top of the cane is parallel to the client's wrist.
- B. When walking
- C. the client moves the cane 46 cm (18 in) forward.
- D. The client holds the cane on the stronger side of her body.
- E. The client moves her stronger limb forward with the cane.
Correct Answer: D
Rationale: Correct Answer: D: The client holds the cane on the stronger side of her body.
Rationale:
1. Holding the cane on the stronger side provides better stability and support.
2. This position allows the client to shift weight onto the cane during walking.
3. It helps to reduce pressure on the weaker side, promoting balance and preventing falls.
Incorrect Choices:
A: The top of the cane parallel to the client's wrist is not directly related to correct use.
B: Walking is a general action, not specific to correct cane use.
C: Specific measurements of cane movement are not essential for correct use.
E: Moving the stronger limb forward with the cane does not ensure proper use.
A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management?
- A. I think I should take my pain medication more often
- B. since it is not controlling my pain.
- C. Breathing faster will help me keep my mind off of the pain.
- D. It might help me to listen to music while I'm lying in bed.
- E. I don't want to walk today because I have some pain.
Correct Answer: C
Rationale: The correct answer is C. The client's statement about breathing faster to keep their mind off the pain indicates understanding of distraction techniques taught preoperatively. This method helps manage pain perception. Choices A and B suggest incorrect self-medication adjustments. Choices D and E do not demonstrate understanding of pain management strategies.
A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?
- A. Position the client at the head of the bed elevated to 30° prior to insertion of the NG tube.
- B. Remove the NG tube if the client begins to gag or choke.
- C. Apply suction to the NG tube prior to insertion.
- D. Have the client take sips of water to promote insertion of the NG tube into the esophagus.
Correct Answer: D
Rationale: Correct Answer: D
Rationale: Having the client take sips of water serves to promote the insertion of the NG tube into the esophagus by facilitating swallowing and opening the esophageal sphincter, making it easier to pass the tube through. This action helps ensure proper placement of the tube in the stomach without risking insertion into the trachea or lungs.
Summary of other choices:
A: Positioning the client at the head of the bed elevated to 30° is important but is not directly related to the insertion of the NG tube.
B: Removing the NG tube if the client gags or chokes is incorrect as these are common responses during insertion, and removing the tube may lead to premature discontinuation.
C: Applying suction to the NG tube prior to insertion is unnecessary and may cause discomfort or damage to the mucosa.
A nurse is assessing a client with heart failure. The client reports increasing shortness of breath, fatigue, and weakness. Which of the following findings in the assessment should the nurse identify as most concerning?
- A. Weak pulses with +2 dependent edema in lower extremities.
- B. Slightly labored respirations at rest.
- C. Wheezes and crackles in the chest.
- D. Reports productive cough during the overnight hours.
Correct Answer: C
Rationale: The correct answer is C: Wheezes and crackles in the chest. This finding is most concerning in a client with heart failure as it indicates potential fluid overload in the lungs, leading to impaired gas exchange and worsening respiratory status. Wheezes suggest bronchoconstriction, while crackles indicate fluid accumulation in the alveoli, both of which can exacerbate shortness of breath. Weak pulses with dependent edema (choice A) are expected in heart failure but do not directly point to acute decompensation. Slightly labored respirations at rest (choice B) may be common in heart failure but do not indicate immediate deterioration. Reports of a productive cough (choice D) can be a sign of fluid retention but are less urgent compared to wheezes and crackles.