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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The client is admitted to the unit with a potassium level of $2.4 \mathrm{meq} / \mathrm{L}$. The client with a potassium level of $2.4 \mathrm{meq} / \mathrm{L}$ would exhibit symptoms of:
- A. Peaked T waves
- B. U waves
- C. Muscle rigidity
- D. Rapid respirations
Correct Answer: B
Rationale: Hypokalemia (low potassium, 2.4 meq/L) causes symptoms like U waves on ECG, muscle weakness, and cramps. Peaked T waves occur in hyperkalemia. Muscle rigidity is not typical, and rapid respirations are more associated with acid-base imbalances.
The nurse is assessing a client at 11 weeks gestation. The first day of the client's last menstrual period was September 7. Which of the following findings should the nurse expect to obtain?
- A. reports feeling fetal movement
- B. reports increased urinary frequency
- C. fundal height of 24 cm above the symphysis pubis
- D. estimated delivery date of June 14 using the Naegele rule
- E. fetal heart tones detectable via Doppler ultrasound device
Correct Answer: B,D,E
Rationale: At 11 weeks, increased urinary frequency (B) is expected due to hormonal changes. The Naegele rule (LMP + 1 year - 3 months + 7 days) gives June 14 (D). Fetal heart tones are detectable by Doppler (E). Fetal movement (A) is felt later (16-20 weeks), and fundal height of 24 cm (C) occurs around 24 weeks.
The nurse is preparing to take a toddler's blood pressure for the first time. Which of the following actions should the nurse perform first?
- A. Explain that the procedure will help him to get well
- B. Show a cartoon character with a blood pressure cuff
- C. Explain that the blood pressure checks the heart pump
- D. Permit handling the equipment before putting the cuff in place
Correct Answer: D
Rationale: Permit handling the equipment before putting the cuff in place. The best way to gain the toddler's cooperation is to encourage handling the equipment. Detailed explanations are not helpful.
The nurse reinforces education about safety modifications in the home for the spouse of a client diagnosed with Alzheimer disease. What instructions should the nurse include?
- A. Arrange furniture to allow for free movement
- B. Keep frequently used items within easy reach
- C. Lock doors leading to stairwells and outside areas
- D. Place an identifying symbol on the bathroom door
- E. Provide a dark room free of shadows for sleeping
Correct Answer: A,B,C,D
Rationale: Clear pathways (A), accessible items (B), locked doors (C), and bathroom symbols (D) enhance safety. A dark room (E) may increase confusion or fear.
A nurse on an orthopedic unit is caring for four clients with a casted extremity. Which client does the nurse prioritize to see first?
- A. Client reporting a tingling sensation
- B. Client reporting itching under the cast
- C. Client reporting pain of 5/10 on movement
- D. Client reporting throbbing on dependent positioning
Correct Answer: A
Rationale: Tingling (A) suggests neurovascular compromise, requiring urgent assessment. Itching (B), moderate pain (C), and throbbing (D) are less critical.