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A nurse is admitting a client who is hesitant to create advance directives due to concerns about affording legal representation. Which of the following statements should the nurse make?
- A. We can initiate medical care until you get legal assistance in preparing your advance directives.
- B. Advance directives can be signed without legal representation.
- C. Advance directives can be a verbal agreement between you and your provider until legal review can be obtained.
- D. A social worker will assist you to find affordable legal representation.
Correct Answer: B
Rationale: Correct Answer: B - Advance directives can be signed without legal representation.
Rationale: Advance directives do not require legal representation to be valid. They are legal documents that outline a person's healthcare wishes in case they are unable to communicate. These documents can be completed by the individual themselves, without the need for a lawyer. By choosing option B, the nurse can provide accurate information and alleviate the client's concerns about the cost of legal representation.
Incorrect Choices:
A: Initiating medical care without advance directives may not align with the client's wishes.
C: Verbal agreements are not legally binding for advance directives.
D: While a social worker can provide resources, legal representation may not be necessary for advance directives.
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A nurse is performing postmortem care for a recently deceased client prior to the client's family viewing. Which of the following actions should the nurse take?
- A. Cross the client's arms across their chest.
- B. Hold the client's eyes shut for a few seconds.
- C. Place the client in a high-Fowler's position.
- D. Remove the client's dentures from their mouth.
Correct Answer: B
Rationale: The correct answer is B: Hold the client's eyes shut for a few seconds. This action is appropriate because it helps create a peaceful appearance for the deceased client, providing a more dignified and comforting view for the family during the viewing. Holding the eyes shut is a common practice to maintain a natural appearance and show respect for the deceased.
Crossing the client's arms (Choice A) is not necessary and may not be culturally appropriate for all families. Placing the client in a high-Fowler's position (Choice C) is not recommended as it may not be comfortable or appropriate for viewing. Removing the client's dentures (Choice D) is also unnecessary and may not be respectful to the deceased.
A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?
- A. Contact
- B. Droplet
- C. Airborne
- D. Protective
Correct Answer: B
Rationale: The correct answer is B: Droplet precautions. Pharyngeal diphtheria is primarily spread through respiratory droplets when an infected person coughs or sneezes. Droplet precautions involve wearing a mask and eye protection within 3 feet of the patient to prevent the transmission of respiratory secretions. Contact precautions (Choice A) are for diseases transmitted through direct contact with the patient or contaminated surfaces. Airborne precautions (Choice C) are for diseases spread through tiny particles that can remain suspended in the air for long periods. Protective precautions (Choice D) are not a standard precaution type.
A nurse is caring for a client who has end-stage liver disease and is undergoing a paracentesis. Which of the following actions should the nurse take to evaluate the effectiveness of the procedure?
- A. Examine for leakage at the site of the procedure.
- B. Compare the client's current weight with preprocedure weight.
- C. Confirm that the client is able to urinate.
- D. Check the client's serum albumin levels.
Correct Answer: B
Rationale: The correct answer is B: Compare the client's current weight with preprocedure weight. This is because paracentesis is a procedure used to remove fluid buildup in the abdomen, which can lead to weight loss. By comparing the client's current weight with the preprocedure weight, the nurse can evaluate the effectiveness of the procedure in draining the excess fluid. This comparison helps determine the amount of fluid removed and assess the client's response to the treatment.
Explanations for why the other choices are incorrect:
A: Examining for leakage at the site of the procedure is important for monitoring for potential complications but does not directly evaluate the effectiveness of the procedure.
C: Confirming that the client is able to urinate is important for assessing kidney function but does not specifically evaluate the effectiveness of the paracentesis.
D: Checking the client's serum albumin levels may provide information about the client's liver function and nutritional status but does not directly evaluate the effectiveness of the paracentesis procedure.
A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?
- A. Check the client for injuries.
- B. Move hazardous objects away from the client.
- C. Notify the provider.
- D. Ask the client to describe how she felt prior to the fall.
Correct Answer: A
Rationale: The correct action is to check the client for injuries first because ensuring the client's immediate safety and well-being is the top priority. By assessing for injuries, the nurse can determine the severity of the situation and provide necessary interventions promptly. Moving hazardous objects (B) can wait until after ensuring the client's safety. Notifying the provider (C) can also be done after assessing the client's condition. Asking the client to describe how she felt prior to the fall (D) is important for gathering information but is not as urgent as checking for injuries.
nurse is auscultating for crackles on a client who has pneumonia. Which of the following anterior chest wall locations should the nurse auscultate? (You will find hot spots to select in the artwork belowi. Select only the hot spot that corresponds to your answer.)
- A. A
- B. B
- C. C
- D. D
Correct Answer:
Rationale: Correct Answer: B
Rationale: Crackles in pneumonia are typically heard in the lower lung fields due to fluid accumulation. Auscultating at location B (lower anterior chest wall) allows for better detection of crackles in the bases of the lungs where pneumonia commonly affects. This area corresponds to the lower lobes where consolidation occurs, leading to crackles. Auscultating at other locations (A, C, D) may not yield clear crackle sounds associated with pneumonia.
Summary of other choices:
A (Location A - upper anterior chest wall): Crackles in pneumonia are typically heard in the lower lung fields due to fluid accumulation.
C (Location C - middle anterior chest wall): Crackles in pneumonia are not typically heard in the middle lung fields.
D (Location D - upper lateral chest wall): Crackles in pneumonia are not typically heard in the upper lateral chest wall.