Nokea
A client with end-stage pulmonary disease requests 'no heroic measures' if she stops breathing. What should the nurse do next?
- A. Document the client's request in the medical record.
- B. Ask the client to discuss a DNR order with her healthcare provider.
- C. Consult the ethics committee for guidance.
- D. Discharge the client with no further discussion.
Correct Answer: B
Rationale: The correct next step for the nurse is to ask the client to discuss a 'do not resuscitate' (DNR) order with her healthcare provider. While the client's wishes should be respected, it is essential to ensure proper documentation and legal protection by involving the healthcare provider in this decision-making process. Documenting the request in the medical record (Choice A) is important but should follow the discussion with the healthcare provider. Consulting the ethics committee (Choice C) may not be necessary at this stage and could delay the necessary actions. Discharging the client (Choice D) without further discussion is not appropriate and disregards the importance of addressing the client's wishes in a respectful and professional manner.
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An older adult client with chronic emphysema is admitted to the emergency room with acute weakness, palpitations, and vomiting. Which information is most important for the nurse to obtain during the initial interview?
- A. Recent compliance with prescribed medications.
- B. Sleep patterns during the previous few weeks.
- C. History of smoking over the past 6 months.
- D. Activity level prior to the onset of symptoms.
Correct Answer: A
Rationale: The correct answer is A: Recent compliance with prescribed medications. In a client with chronic emphysema experiencing acute symptoms, it is crucial to assess medication compliance as it directly impacts the management of the condition and could contribute to the current presentation. Ensuring that the client has been taking their prescribed medications can provide vital information to guide further treatment. Choices B, C, and D, although important in a comprehensive assessment, are not as immediately crucial as assessing medication compliance in this emergency situation.
A 4-year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do first?
- A. Notify the healthcare provider
- B. Readjust the traction
- C. Administer the ordered PRN medication
- D. Reassess the foot in fifteen minutes
Correct Answer: A
Rationale: A pale foot with no pulse suggests a compromised blood supply, indicating a potential vascular emergency. The nurse's immediate priority is to notify the healthcare provider to address the situation promptly. Readjusting the traction, administering PRN medication, or waiting to reassess the foot later could lead to serious complications due to the compromised blood supply, making choices B, C, and D incorrect in this critical situation.
After completing her first chemotherapy treatment, what behavior indicates that a female client with breast cancer understands her discharge care needs?
- A. She refuses to take anti-nausea medication.
- B. She rents movies and borrows books to pass time at home.
- C. She plans to resume strenuous physical activity immediately.
- D. She reports severe fatigue and inability to perform daily activities.
Correct Answer: B
Rationale: Renting movies and borrowing books for use during recovery indicates the client is planning restful activities at home, which aligns with appropriate post-chemotherapy care. Choices A, C, and D are incorrect because refusing anti-nausea medication can lead to complications, resuming strenuous physical activity immediately can be harmful, and reporting severe fatigue and inability to perform daily activities may indicate a need for medical attention rather than understanding discharge care needs.
A client with hypertension is prescribed a thiazide diuretic. What dietary recommendation should the nurse make?
- A. Encourage a diet low in carbohydrates and fats.
- B. Avoid foods high in vitamin K, such as spinach and kale.
- C. Increase salt intake to prevent dehydration.
- D. Eat potassium-rich foods like bananas and oranges.
Correct Answer: D
Rationale: The correct answer is D: 'Eat potassium-rich foods like bananas and oranges.' Thiazide diuretics can lead to potassium loss, so it is essential for clients to consume potassium-rich foods to maintain adequate levels. Choice A is incorrect because focusing solely on low carbohydrates and fats does not address the specific issue of potassium loss. Choice B is unrelated as vitamin K content is not a concern with thiazide diuretics. Choice C is incorrect as increasing salt intake would exacerbate hypertension and not prevent dehydration.
An older client with chronic emphysema is admitted to the emergency room with acute weakness, palpitations, and vomiting. Which information is most important for the nurse to obtain during the initial interview?
- A. Recent compliance with prescribed medications.
- B. Sleep patterns during the previous few weeks.
- C. History of smoking over the past 6 months.
- D. Activity level prior to the onset of symptoms.
Correct Answer: A
Rationale: The correct answer is A. In this scenario, the most critical information for the nurse to obtain during the initial interview is the recent compliance with prescribed medications. This is crucial to understand the client's baseline condition and management of chronic emphysema. Monitoring medication adherence can provide insights into potential exacerbating factors that may have led to the current acute symptoms. Choices B, C, and D are not as crucial in this situation. Sleep patterns, smoking history, and activity levels are important aspects of the client's overall health but do not take precedence over medication compliance when addressing acute symptoms in a client with chronic emphysema.