Nokea
A client with terminal cancer expresses fear of dying alone. The nurse's most therapeutic response is:
- A. You won't be alone; we'll ensure someone is with you.
- B. Everyone dies alone, but it's not something to fear.
- C. Let's focus on keeping you comfortable instead.
- D. Have you considered spiritual counseling?
Correct Answer: A
Rationale: Assuring the client that someone will be present addresses their fear directly, providing emotional reassurance and support.
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Which activity increases the risk of renal calculi?
- A. High fluid intake.
- B. Sedentary lifestyle.
- C. Low-sodium diet.
- D. Frequent urination.
Correct Answer: B
Rationale: A sedentary lifestyle promotes urinary stasis, increasing stone risk.
The nurse is preparing a staff education program about medication reconciliation. Which of the following information should the nurse include? Select all that apply.
- A. Discontinued medications should be included while performing medication reconciliation.
- B. Medications taken on an as-needed basis can be excluded from this process.
- C. New medication orders should be compared with the current list.
- D. Medication reconciliation should be performed after the client has been discharged.
- E. Over-the-counter (OTC) medications should be included in the medication reconciliation.
Correct Answer: A,C,E
Rationale: Medication reconciliation includes discontinued medications, new orders, and OTC medications to ensure a complete and accurate list; it should occur at admission, transfer, and discharge, and PRN medications should not be excluded.
Which complication should the nurse monitor for in a client with a new ileal conduit?
- A. Stoma prolapse.
- B. Urinary retention.
- C. Bladder spasms.
- D. Renal colic.
Correct Answer: A
Rationale: Stoma prolapse is a potential complication of an ileal conduit, requiring surgical correction if severe.
A health care provider orders 0.5 mg of protamine sulfate for a client who is showing signs of bleeding after receiving a 100-unit dose of heparin. The nurse should expect the effects of the protamine sulfate to be noted in which of the following time frames?
- A. 5 minutes.
- B. 10 minutes.
- C. 20 minutes.
- D. 30 minutes.
Correct Answer: C
Rationale: Protamine sulfate neutralizes heparin rapidly, with effects typically seen within 20 minutes of administration. This allows for quick reversal of heparin's anticoagulant effects in cases of bleeding. The other time frames are either too short or too long.
The physician orders intestinal decompression with a Cantor tube for a client with an intestinal obstruction. In order to determine effectiveness of intestinal decompression the nurse should evaluate the client to determine if:
- A. Fluid and gas have been removed from the intestine.
- B. The client has had a bowel movement.
- C. The client's urinary output is adequate.
- D. The client can sit up without pain.
Correct Answer: A
Rationale: The effectiveness of a Cantor tube is determined by the removal of fluid and gas from the intestine, relieving the obstruction. Bowel movements, urinary output, or sitting up without pain are not direct indicators of decompression success. CN: Physiological adaptation; CL: Evaluate