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A client is in the terminal stage of lung cancer. Outside the room, the client's spouse expresses to the nurse feelings of helplessness and a lack of hope for the future. How should the nurse respond?
- A. Offer comfort that healing can happen at any point in time.
- B. Offer strategies the spouse can use to provide comfort to the client.
- C. Suggest that the spouse go home for a while and get some sleep.
- D. Explain that the staff will strive to keep the client comfortable.
Correct Answer: D
Rationale: Reassurance about care addresses concerns.
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The nurse is providing postoperative teaching to a client on ways to prevent constipation. Which information should the nurse include?
- A. Drink 800 to 1,000 milliliters of fluid daily.
- B. Take oxycodone as scheduled to prevent painful bowel movements.
- C. Add fat-containing foods in the diet to lubricate stools for easier passage.
- D. Ambulate early and as frequently as possible.
Correct Answer: D
Rationale: Ambulation stimulates bowel function.
The nurse is reviewing the signed operative consent with a client who is admitted for the removal of a lipoma on the left leg. The client reports the permit should include another lipoma on the right leg. Which action should the nurse implement?
- A. Have the client sign a new surgical permit.
- B. Inform the surgeon about the client's concern.
- C. Add the additional information to the permit.
- D. Notify the surgical staff of the client's confusion.
Correct Answer: B
Rationale: Surgeon must evaluate and amend consent.
While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?
- A. C-reactive protein level
- B. Serum potassium and sodium levels
- C. Neutrophil count
- D. Platelet count
Correct Answer: A
Rationale: CRP indicates inflammation, but neutrophils are more specific for infection.
The nurse is teaching a spouse how to care for a client who recently had a stroke and has residual weakness on the right side. Which style of shoes should the nurse recommend the client wear when ambulating with the spouse's assistance?
- A. Slip-on rubber shower shoes
- B. Tennis shoes with Velcro
- C. Leather-soled loafers
- D. Rubber-soled slippers
Correct Answer: B
Rationale: Velcro shoes provide support and ease of use.
A patient with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the patient's fluid balance?
- A. Skin turgor.
- B. Weight.
- C. Blood pressure.
- D. Lung sounds.
Correct Answer: B
Rationale: Daily weight accurately tracks fluid balance.