Nokea
A client receiving end-of-life care is no longer able to make decisions. The client's appointed medical power of attorney (MPOA) is considering placement of a percutaneous enterogastric feeding tube. The MPOA asks the nurse, 'What would you do if this was your family member?' How should the nurse respond?
- A. I'm not sure what I would do, but I feel confident that you will make the right decision.
- B. I will call the chaplain to help you sort through the options and discuss the issue.
- C. What do you think are the advantages and disadvantages of a feeding tube?
- D. You should meet with the family to discuss what the patient would have wanted.
Correct Answer: C
Rationale: Exploring pros and cons (C) empowers the MPOA to make an informed decision. Personal opinions (A), chaplain referral (B), or family meetings (D) are less direct.
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A client with a diagnosis of HPV is at risk for which of the following?
- A. Hodgkin's lymphoma
- B. Cervical cancer
- C. Multiple myeloma
- D. Ovarian cancer
Correct Answer: B
Rationale: The client with HPV is at higher risk for cervical and vaginal cancer related to this STI. She is not at higher risk for the cancers mentioned in answers A, C, and D, so those are incorrect.
The nurse assesses a client for physiological risk factors for falls. The nurse should conclude that the client is not at risk if which of the following is discovered?
- A. history of dizziness
- B. need for wheelchair due to reduced mobility
- C. weakness and fatigue noted when climbing stairs
- D. intact recent and remote memory
Correct Answer: D
Rationale: Intact recent and remote memory indicates that a client is not at risk for falls. Risk for falls can occur in elder clients, and the nurse should assess each client for the possibility of falls and take appropriate actions.
The intensive care nurse is caring for a client who has just been extubated. Which interventions are appropriate at this time?
- A. Administer prescribed oral narcotics for throat pain
- B. Administer warmed, humidified oxygen via facemask
- C. Give the client ice chips to moisten the mouth
- D. Provide mouth care with oral sponges
- E. Start the client on incentive spirometer
Correct Answer: B,C,D,E
Rationale: Post-extubation, warmed, humidified oxygen (B) prevents mucosal drying, ice chips (C) moisten the mouth, oral sponges (D) maintain hygiene, and incentive spirometry (E) promotes lung expansion. Oral narcotics (A) are risky due to potential airway compromise.
The nurse in a same-day surgery unit assigns the unlicensed assistive personnel (UAP) to provide a hernia patient with a lunch tray. Which statement by the nurse is most appropriate?
- A. Tell the family they can bring in a pizza if the patient would prefer that.
- B. Make sure the patient gets at least 2 cartons of milk
- C. Stop the IV if the patient is able to eat solid food.
- D. Encourage the patient to eat slowly to prevent gas.
Correct Answer: D
Rationale: The professional nurse can delegate tasks with an expected outcome. The UAP is given adequate information about the task and how to promote the best outcome.
A nurse is preparing an educational presentation on herbal supplements for the local community center. The nurse anticipates discussion of saw palmetto to what type of clients?
- A. Clients diagnosed with dyslipidemia
- B. Clients experiencing major depression
- C. Clients with benign prostatic hyperplasia
- D. Perimenopausal clients experiencing hot flashes
Correct Answer: C
Rationale: Saw palmetto is commonly used for benign prostatic hyperplasia (C) to relieve urinary symptoms. It is not indicated for dyslipidemia (A), depression (B), or hot flashes (D).