Nokea
A client with prostate cancer has been given the option of various treatments and asks the nurse for advice. Which of the following is the most appropriate response?
- A. Let's discuss the different options and how you feel about them.'
- B. I can't help you to make a treatment decision about your treatment.'
- C. You need to discuss this decision with your physician.'
- D. I would choose surgery if I were in your position.'
Correct Answer: A
Rationale: Discussing options and feelings (A) supports the client's decision-making without giving direct advice. Other responses (B, C, D) dismiss the client's request or overstep the nurse's role.
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The charge nurse on a surgical unit incorporates an authoritative style of leadership. Which characteristics describe this style of leadership? Select all that apply.
- A. involves little planning
- B. motivates staff by coercion
- C. motivates staff by supporting their achievements
- D. involves communication flow down the chain of command
- E. includes group members in the decision-making process
Correct Answer: B, D
Rationale: Authoritative leadership involves top-down communication and can use coercion to motivate, focusing on control rather than collaboration or support.
Which of the following factors increase the risk of developing deep vein thrombosis (DVT)? Select all that apply.
- A. Being underweight
- B. Smoking
- C. Having surgery
- D. Taking oral contraceptives
- E. High-protein diet
- F. Immobility
Correct Answer: B,C,D,F
Rationale: DVT risk factors include smoking (B), surgery (C), oral contraceptives (D), and immobility (F). Underweight (A) and high-protein diet (E) are not significant risks.
The physician has ordered 2 units of whole blood for a client following surgery. To provide for client safety, the nurse should:
- A. Obtain a signed permit for each unit of blood
- B. Use a new administration set for each unit transfused
- C. Administer the blood using a $Y$ connector
- D. Check the blood type and Rh factor three times before initiating the transfusion
Correct Answer: B
Rationale: Using a new administration set for each unit prevents contamination and ensures accurate delivery, enhancing transfusion safety.
A client with alcoholism has been instructed to increase his intake of thiamine. The nurse knows the client understands the instructions when he selects which food?
- A. Roast beef
- B. Broiled fish
- C. Baked chicken
- D. Sliced pork
Correct Answer: D
Rationale: Sliced pork is a rich source of thiamine (vitamin B1), which is critical for preventing Wernicke's encephalopathy in clients with alcoholism.
The nurse is making a home visit to an elderly client during the summer. Upon arrival, the nurse notices the refrigerator and freezer doors are open as the client is using both for air conditioning. Which of the following actions by the nurse are most appropriate?
- A. instruct the client to place a fan in front of the freezer to enhance circulation of cool air
- B. hold a meeting with the client and family to advise them of the safety risks of this practice
- C. note this observation in the client's medical record, but do not discuss with the client
- D. report the incident to the nursing supervisor
Correct Answer: B
Rationale: Discussing the risks (e.g., food spoilage, electrical hazards) with the client and family promotes safety and education.