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A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make?
- A. I will return shortly after I document this in your record.
- B. Most men live a long time with prostate cancer.
- C. I am available to talk if you should change your mind.
- D. I will make a referral to a cancer support group for you.
Correct Answer: C
Rationale: The correct answer is C: "I am available to talk if you should change your mind." This response shows the nurse's willingness to provide support and maintain an open line of communication without being intrusive. It respects the client's current decision while also conveying availability for future discussions, promoting trust and rapport.
A: Incorrect. This response prioritizes documentation over the client's emotional needs.
B: Incorrect. While well-intentioned, this statement may offer false reassurance and overlooks individual variability in prognosis.
D: Incorrect. Referring to a support group without the client's consent may not align with their current preferences.
E: Incorrect. Incomplete choice.
F: Incorrect. Incomplete choice.
G: Incorrect. Incomplete choice.
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A nurse is caring for a client who has a peripheral IV inserted for fluid. The nurse is assessing the client. Which of the following actions should the replacement nurse take? Select all that apply. Nurses' Notes: Day 1: Client's left arm. Lactated Ringer's at 100 mL/hr infusing into a 20-gauge IV catheter in left hand. IV dressing dry and intact. IV site without redness or swelling. IV fluid infusing well. Day 2: Start a new IV in the client's left hand. IV site edematous. Skin surrounding catheter site taut, blanched, and cool to touch. IV fluid not infusing.
- A. Stop the IV infusion.
- B. Place a pressure dressing over the IV site.
- C. Apply heat to the client's left hand.
- D. Start a new IV in a different site.
Correct Answer: A, B, C
Rationale: Correct Answer: A, B, C
Rationale:
A: Stop the IV infusion - The IV site is showing signs of infiltration (edematous, blanched, cool skin, IV fluid not infusing). Stopping the infusion prevents further harm.
B: Place a pressure dressing over the IV site - A pressure dressing helps reduce swelling and prevent further infiltration.
C: Apply heat to the client's left hand - Applying heat can help improve blood flow and absorption of any infiltrated fluids, aiding in the resolution of the issue.
Summary:
D: Starting a new IV in a different site would be premature without addressing the current issue of infiltration.
E, F, G: No other actions are indicated based on the information provided.
A nurse is caring for 3 clients who have COPD. Select the 3 findings that require follow-up. Nurses' Notes: Temperature 100°F, oxygen saturation 88%, blood pressure 130/80 mmHg. Client admitted with a productive cough with thick yellow sputum. Breath sounds with crackles heard in the left upper lobe and decreased breath sounds at bases bilaterally. Heart rate 98 beats/min.
- A. Temperature 100°F
- B. Oxygen saturation 88%
- C. Blood pressure 130/80 mmHg
- D. Heart rate 98 beats/min
Correct Answer: A, B, D
Rationale: The correct answers are A, B, and D. A temperature of 100°F indicates possible infection or inflammation, warranting follow-up. An oxygen saturation of 88% is below the normal range, indicating hypoxemia. A heart rate of 98 beats/min is elevated, suggesting increased work of breathing or stress on the cardiovascular system. Choice C, blood pressure of 130/80 mmHg, falls within the normal range and does not require immediate follow-up. Choices E, F, and G are not relevant findings in this scenario.
A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies?
- A. Biofeedback
- B. Aloe
- C. Reflexology
- D. Acupuncture
Correct Answer: D
Rationale: The correct answer is D: Acupuncture. Herpes zoster, also known as shingles, is a viral infection that affects the nerves and causes a painful rash. Acupuncture involves inserting thin needles into specific points on the body to alleviate pain and promote healing. However, in the case of herpes zoster, the skin lesions and nerve involvement increase the risk of spreading the virus through acupuncture needles, leading to potential complications. Therefore, acupuncture is contraindicated in clients with herpes zoster to prevent the spread of the virus.
A: Biofeedback, B: Aloe, and C: Reflexology are not contraindicated for clients with herpes zoster. Biofeedback is a non-invasive technique that helps individuals control physiological processes such as reducing stress and managing pain. Aloe is a natural plant extract commonly used for its anti-inflammatory and soothing properties, which can be beneficial for skin irritations caused by herpes zoster. Reflexology is a therapeutic technique that involves applying pressure to
A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol?
- A. The client uses a wool blanket on their bed.
- B. The client identifies the location of the fire extinguisher.
- C. The client stores an oxygen tank in a secure outdoor shed.
- D. The client has a weekly inspection checklist for oxygen equipment.
Correct Answer: D
Rationale: The correct answer is D because a weekly inspection checklist for oxygen equipment ensures that the equipment is functioning properly and reduces the risk of potential hazards. Option A is incorrect because wool blankets can create static electricity, which is a fire hazard. Option B is not directly related to oxygen safety. Option C is incorrect as storing an oxygen tank in an outdoor shed may expose it to extreme temperatures or moisture.
A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
- A. Place a name tag on the body.
- B. Obtain the pronouncement of death from the provider.
- C. Remove tubes and indwelling lines.
- D. Wash the client's body.
- E. Ask the client's family members if they would like to view the body.
Correct Answer: B, E, C, D, A
Rationale: 1. Obtain the pronouncement of death from the provider (B): This is the first step to officially confirm the client's passing.
2. Ask the client's family members if they would like to view the body (E): Providing support to the family is crucial.
3. Remove tubes and indwelling lines (C): This step is necessary to prepare the body for respectful handling.
4. Wash the client's body (D): Maintaining dignity and cleanliness is important.
5. Place a name tag on the body (A): This ensures proper identification for all involved.
In summary, obtaining the pronouncement of death is the priority, followed by addressing the emotional needs of the family, preparing the body, and ensuring proper identification. Removing tubes and washing the body come before placing the name tag.