Nokea
A client with a terminal illness asks the nurse about what would happen if she arrived at the emergency department and had difficulty breathing, despite declining resuscitation in her living will. Which of the following responses should the nurse provide?
- A. We will determine who the durable power of attorney for health care form has designated.
- B. We will apply oxygen through a tube in your nose.
- C. We will ask if you have changed your mind.
- D. We will insert a breathing tube while we evaluate your condition.
Correct Answer: B
Rationale: The correct response is to provide oxygen through a tube in the client's nose. Oxygen therapy can offer comfort and support breathing without being considered resuscitative. Therefore, this intervention aligns with the client's wish to decline resuscitation. Option A is not directly related to addressing the client's immediate breathing difficulty. Option C does not acknowledge the client's living will decision. Option D involves a more invasive procedure that may go against the client's wishes to decline resuscitation.
You may also like to solve these questions
A healthcare professional is planning care for a female client who has an indwelling urinary catheter. Which of the following actions should the healthcare professional include in the plan?
- A. Empty the drainage bag at least every 8 hours
- B. Keep the drainage bag below the level of the bladder
- C. Use sterile technique to collect a specimen from the drainage system
- D. Secure the catheter to the lower abdomen with a securement device
Correct Answer: B
Rationale: The correct action to include in the plan is to keep the drainage bag below the level of the bladder. This positioning helps ensure proper drainage and prevents backflow of urine into the bladder, reducing the risk of urinary tract infections. Emptying the drainage bag regularly is important, typically every 4-8 hours or when it is half-full, to maintain adequate flow and prevent infection (Choice A is incorrect). Using a sterile technique to collect specimens from the drainage system is crucial to prevent introducing pathogens into the urinary tract, so clean technique should not be used (Choice C is incorrect). Taping the catheter to the lower abdomen is not recommended as it can cause tension on the catheter, leading to discomfort and potential trauma to the urethra (Choice D is incorrect).
What instruction should the nurse provide for a UAP caring for a client with MRSA who has a prescription for contact precautions?
- A. Allow visitors with precautions in place
- B. Wear sterile gloves when handling the client's body fluid
- C. Have the client wear a mask whenever someone enters the room
- D. Don a gown and gloves when entering the room
Correct Answer: D
Rationale: The correct instruction for a UAP caring for a client with MRSA under contact precautions is to don a gown and gloves when entering the room. Wearing a gown and gloves is necessary to prevent the transmission of MRSA. Choice A is incorrect because visitors may be allowed with proper precautions in place. Choice B is incorrect as it assumes the client has body fluid precautions, which is not specified. Choice C is incorrect as it does not address the UAP's protective measures but rather focuses on the client wearing a mask.
A client is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?
- A. Ask the client to consider a direct donation
- B. Withhold the blood transfusion
- C. Request a consultation with the ethics committee
- D. Ask the client's family to intervene
Correct Answer: B
Rationale: The correct action for the nurse to take in this situation is to withhold the blood transfusion. The principle of autonomy ensures that a competent client has the right to refuse treatment, even if their decision conflicts with the wishes of their partner or family. Asking the client to consider a direct donation (Choice A) is not appropriate as it disregards the client's autonomy and religious beliefs. Requesting a consultation with the ethics committee (Choice C) may be considered in complex ethical dilemmas, but in this case, the client's autonomy should be respected first. Asking the client's family to intervene (Choice D) is not appropriate as the client has the right to make their own healthcare decisions based on their religious beliefs.
A female client with chronic back pain has been taking muscle relaxants and analgesics to manage the discomfort, but is now experiencing an acute episode of pain that is not relieved by this medication regime. The client tells the nurse that she does not want to have back surgery for a herniated intervertebral disk, and reports that she has found acupuncture effective in resolving past acute episodes. Which response is best for the nurse to provide?
- A. Surgery removes the disk and is the only treatment that can totally resolve the pain
- B. The medication regimen you previously used should be re-evaluated for dose adjustment
- C. Massage and hot pack treatments are less invasive and can provide temporary relief
- D. Acupuncture is a complementary therapy that is often effective for management of pain
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client is recovering from gallbladder surgery performed under general anesthesia. How many times per hour should the nurse encourage the client to use the incentive spirometer?
- A. 4-5 times per hour
- B. 2-3 times per hour
- C. 6-7 times per hour
- D. 8-10 times per hour
Correct Answer: A
Rationale: Encouraging the client to use the incentive spirometer 4-5 times per hour is the correct approach post-gallbladder surgery under general anesthesia. This frequency helps prevent respiratory complications, such as atelectasis, by promoting lung expansion. Choices B, C, and D suggest either too few or too many sessions per hour, which may not be optimal for the client's respiratory recovery needs. It is important to strike a balance between ensuring adequate lung expansion and not overexerting the client, which is why 4-5 times per hour is the recommended frequency.