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A client scheduled for cataract surgery tells the nurse, 'I see just fine and have decided to cancel my surgery.' What should the nurse do?
- A. Proceed with the surgery as planned
- B. Document the refusal and inform the surgeon
- C. Explain the benefits of the surgery
- D. Respect the client's decision
Correct Answer: C
Rationale: In this scenario, the nurse should explain the benefits of the surgery to the client. By providing more information, the client may reconsider their decision after understanding the positive impact the surgery could have on their vision. Proceeding with the surgery against the client's wishes (Choice A) is not ethical and goes against the principle of autonomy. While documenting the refusal and informing the surgeon (Choice B) is important for the client's medical record, it is crucial to first try to educate the client about the benefits. Simply respecting the client's decision (Choice D) without attempting to provide more information may not be in the client's best interest.
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A nurse is caring for a client who has dementia and frequently tries to get out of bed. What actions should the nurse take? (Select all that apply)
- A. Turn off the bed alarm
- B. Use physical restraints
- C. Maintain the bed in the lowest position
- D. Apply a vest restraint
Correct Answer: C
Rationale: Maintaining the bed in the lowest position is an appropriate action when caring for a client with dementia who tries to get out of bed. This helps reduce the risk of falls and ensures the client's safety. Turning off the bed alarm (Choice A) is not advisable as it can be a safety measure to alert the staff when the client tries to get out of bed. Using physical restraints (Choice B) and applying a vest restraint (Choice D) should be avoided as they can lead to physical and psychological harm, reduce mobility, and compromise the client's dignity.
A nurse is assessing a client who reports pain and redness at the site of a peripheral IV. What should the nurse do first?
- A. Apply a cold compress to the site
- B. Discontinue the IV line
- C. Notify the provider
- D. Increase the IV flow rate
Correct Answer: B
Rationale: When a client reports pain and redness at the site of a peripheral IV, indicating signs of phlebitis, the nurse's initial action should be to discontinue the IV line. This helps prevent further complications and ensures patient safety. Applying a cold compress (Choice A) may provide temporary relief but does not address the underlying issue. Notifying the provider (Choice C) is important but not the initial step. Increasing the IV flow rate (Choice D) can exacerbate the inflammation and should be avoided.
When providing discharge teaching to a client prescribed home oxygen therapy, what information should the nurse include?
- A. Increase the oxygen flow rate during activity
- B. Avoid smoking and open flames near oxygen
- C. Store the oxygen tank in a warm, dry place
- D. Turn off the oxygen when not in use
Correct Answer: B
Rationale: The correct answer is B: 'Avoid smoking and open flames near oxygen.' This information is crucial to prevent fire hazards when using home oxygen therapy. Smoking and open flames near oxygen can lead to serious accidents. Choice A is incorrect because increasing the oxygen flow rate during activity without healthcare provider guidance can be dangerous. Choice C is incorrect as oxygen tanks should be stored in a well-ventilated area, not necessarily warm and dry. Choice D is incorrect as oxygen should not be turned off and on by the client, as it can affect the therapy's effectiveness and cause safety issues.
A client is being taught by a nurse about the correct use of a metered-dose inhaler (MDI). What instruction should the nurse include?
- A. Inhale for 1 second
- B. Hold the inhaler 1-2 inches from the mouth
- C. Exhale immediately after inhaling
- D. Hold the inhaler directly at the lips
Correct Answer: B
Rationale: The correct instruction the nurse should include when teaching a client about using a metered-dose inhaler (MDI) is to hold the inhaler 1-2 inches from the mouth. This distance ensures proper delivery of the medication into the airways. Choices A, C, and D are incorrect because inhaling for a specific duration, exhaling immediately after inhaling, or holding the inhaler directly at the lips are not recommended practices for the correct use of an MDI.
A nurse is performing a focused assessment on a client with a history of chronic obstructive pulmonary disease (COPD). What finding should the nurse expect?
- A. Increased breath sounds
- B. Flushed skin
- C. Nasal flaring
- D. Decreased respiratory rate
Correct Answer: B
Rationale: The correct answer is B: Flushed skin. Flushed skin is a common finding in clients with COPD who are experiencing dyspnea. Increased breath sounds (choice A) are not typically associated with COPD; they may indicate conditions like pneumonia. Nasal flaring (choice C) is more commonly seen in respiratory distress in pediatric patients. Decreased respiratory rate (choice D) is not a typical finding in COPD and could indicate respiratory depression.