Nokea
A client on hospice home care is taking sips of water but refusing food. Family members appear distressed and insist that the personal care worker 'force feed' the client. What is the priority nursing action?
- A. Explain to the family that this is a normal physiological response to dying
- B. Explore the family’s thoughts and concerns about the client’s refusal of food
- C. Recommend a feeding tube
- D. Tell the family that 'force feeding' the client could cause the client to choke on the food
Correct Answer: A
Rationale: Explaining that anorexia is normal in dying (A) addresses family distress and aligns with hospice goals. Exploring concerns (B) is secondary, feeding tubes (C) are inappropriate, and choking warnings (D) may escalate distress.
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A client has been hospitalized after an automobile accident. A full leg cast was applied in the emergency room. The most important reason for the nurse to elevate the casted leg is to
- A. Promote the client's comfort
- B. Reduce the drying time
- C. Decrease irritation to the skin
- D. Improve venous return
Correct Answer: D
Rationale: Elevating the leg both improves venous return and reduces swelling. Client comfort will be improved as well.
A client is receiving IV potassium. The IV pump displays an occlusion alarm. The tubing is free of occlusions, and the IV flushes easily without symptoms of infiltration. Which action should the nurse take next?
- A. Discard potassium and document administration of a partial dose
- B. Exchange the IV pump with a different one
- C. Insert a new IV catheter in a different location
- D. Remove the pump and administer medication by gravity drip
Correct Answer: B
Rationale: An occlusion alarm with patent tubing suggests a pump malfunction. Exchanging the pump (B) ensures safe delivery. Discarding (A) is unnecessary, a new catheter (C) is not indicated, and gravity drip (D) risks rapid infusion.
A client is to be discharged on enoxaparin (Lovenox) for the next two days. Which comment by the client indicates a need for further instruction?
- A. I will wash my hands before I prepare the injection.
- B. I will give the injection in my thigh.
- C. I will pinch the skin before I inject the medicine.
- D. I will not massage the area after the shot.
Correct Answer: B
Rationale: Enoxaparin is injected subcutaneously in the abdomen, not the thigh, indicating a need for further teaching.
A mother brings her 1-month-old son to the clinic for a well-baby visit. The child has a moderately severe hypospadias that was seen by a urologist in the newborn nursery. The mother is upset that the doctors would not circumcise her son before he was discharged. What information should the nurse include when responding to the mother?
- A. The foreskin should not be removed because it will be used in the repair of the hypospadias.
- B. The child's condition did not allow for elective surgery. It will be done at a later date when he is stronger.
- C. Circumcision is a surgical procedure. Because he will have surgery in the near future, it will be done at the same time to avoid two surgeries close together.
- D. The procedure was not done because circumcision is medically unnecessary, not because he has a hypospadias.
Correct Answer: A
Rationale: Hypospadias repair often uses foreskin tissue, so circumcision is avoided to preserve it for surgical correction, addressing the mother's concern.
A client diagnosed with trichomonal vaginal infection (trichomoniasis) is prescribed metronidazole. Which directions are essential for the nurse to reinforce? Select all that apply.
- A. Avoid alcohol while taking this medication
- B. Perform vaginal douche for 7-10 days
- C. Use birth control pills to prevent infection recurrence
- D. Your partner(s) must be treated simultaneously
- E. Your urine can change to a deep red-brown color
Correct Answer: A,D,E
Rationale: Metronidazole treatment for trichomoniasis requires specific instructions. Avoiding alcohol (A) prevents a disulfiram-like reaction. Partner treatment (D) is essential to prevent reinfection, as trichomoniasis is sexually transmitted. Urine discoloration (E) is a possible side effect to anticipate. Douching (B) is not recommended, as it disrupts vaginal flora. Birth control pills (C) do not prevent recurrence of this infection.