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A nurse is assessing a group of clients for hospice services. The nurse should recommend hospice care for which of the following clients?
- A. A client who has diabetes mellitus and is having difficulty self-administering insulin because of poor eye sight
- B. A client who has terminal cancer and needs assistance with pain management
- C. A client who has dementia and needs help with activities of daily living
- D. A client who is recovering from a stroke and needs someone to provide care while his spouse is at work
Correct Answer: B
Rationale: The correct answer is B because hospice care is appropriate for clients with terminal illnesses who require palliative care, such as pain management. This client's terminal cancer indicates a need for hospice services to provide comfort and support during end-of-life care. Choices A, C, and D do not meet the criteria for hospice care as they do not involve terminal illness requiring palliative care. Choice A's issue can be managed with assistance, choice C's issue is related to dementia care, and choice D's issue is related to post-stroke care.
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A nurse is caring for four clients on a medical-surgical unit. Which of the following clients should the nurse assess first?
- A. A client who has COPD and the capillary refill time on both hands is 4 seconds
- B. A client who has late-stage cirrhosis and whose breath has a fruity odor
- C. A client who has a nasogastric tube for decompression and the gastric aspirate is green with a pH of 5.3
- D. A client who had an indwelling urinary catheter removed 5 hr ago and has not voided
Correct Answer: D
Rationale: The correct answer is D. The nurse should assess the client who had an indwelling urinary catheter removed 5 hours ago and has not voided first. This situation raises concerns about urinary retention, which can lead to bladder distension, discomfort, and potential complications like urinary tract infections. Prompt assessment and intervention are necessary to prevent further issues.
Choice A is incorrect because a capillary refill time of 4 seconds in a client with COPD may suggest impaired circulation but is not as urgent as urinary retention. Choice B is incorrect as fruity odor in late-stage cirrhosis may indicate hepatic encephalopathy but is not an immediate priority. Choice C is incorrect as green gastric aspirate with a pH of 5.3 may indicate bile reflux but not as urgent as urinary retention.
A nurse is delegating tasks to an assistive personnel (AP) for a client with a pressure injury. Which of the following tasks is appropriate for the AP to perform?
- A. Assess the stage of the pressure injury.
- B. Reposition the client every 2 hours.
- C. Apply a prescribed wound dressing.
- D. Evaluate the client's skin integrity.
Correct Answer: B
Rationale: Repositioning the client every 2 hours is a routine task that helps prevent further skin breakdown and is within the AP's scope of practice. Assessment, dressing application, and evaluation require nursing judgment.
A home health nurse is planning care for a client who has Alzheimer's disease. The client's partner is her primary caregiver and reports not having enough time to complete his errands. Which of the following referrals should the nurse plan to make?
- A. Respite care
- B. Restorative care
- C. Hospice care
- D. Mental health care
Correct Answer: A
Rationale: The correct answer is A: Respite care. This is the most appropriate referral for the client's partner who needs time off from caregiving responsibilities to complete errands. Respite care provides temporary relief for the primary caregiver, allowing them to take a break while ensuring the client's needs are still met. This helps prevent caregiver burnout and promotes overall well-being for both the caregiver and the client.
Choices B, C, and D are incorrect:
B: Restorative care focuses on restoring the client's functional abilities and independence, which is not directly related to the partner's need for time off.
C: Hospice care is for clients with terminal illnesses who are no longer receiving curative treatment, which is not applicable in this scenario.
D: Mental health care may be beneficial for the client or caregiver in managing emotions and stress, but it does not address the immediate need for respite care.
A nurse is caring for four postoperative clients. The nurse can delegate obtaining vital signs to an assistive personnel (AP) for which of the following clients?
- A. A client who is 3 days postoperative following a craniotomy
- B. A client who is 3 days postoperative following gastric bypass surgery
- C. A client who is 2 hr postoperative following an abdominal hysterectomy
- D. A client who is 1 hr postoperative following a thyroidectomy
Correct Answer: B
Rationale: The correct answer is B because a client who is 3 days postoperative following gastric bypass surgery is stable and unlikely to have immediate complications. Vital signs can be safely delegated to an assistive personnel (AP) for this client.
Choice A is incorrect because a client who is 3 days postoperative following a craniotomy may still be at risk for neurological complications that require close monitoring by a nurse.
Choice C is incorrect because a client who is only 2 hours postoperative following an abdominal hysterectomy is still in the immediate postoperative period and requires frequent monitoring by a nurse.
Choice D is incorrect because a client who is only 1 hour postoperative following a thyroidectomy is in the immediate postoperative period and may have potential complications that require close monitoring by a nurse.
Overall, the key factor in delegating obtaining vital signs to an AP is the stability of the client's condition postoperatively.
A nurse is teaching a class on torts. The nurse should include which of the following situations as an example of negligence?
- A. A client who is alert and oriented makes an informed decision to leave the hospital against medical advice. The nurse applies restraints to the client to prevent him from leaving.
- B. A nurse identifies the absence of peripheral pulsation in a casted extremity in the early morning and reports it to the provider in the early afternoon.
- C. A client who is competent refuses an antidepressant medication. The nurse dissolves the medication in food and administers it to her without her knowledge.
- D. A nurse finds a client who is on a low-sodium diet eating salted potato chips. The nurse tells the client that she will apply wrist restraints if he does not stop eating the potato chips.
Correct Answer: C
Rationale: The correct answer is C because administering medication without the client's knowledge and against their refusal constitutes a breach of the duty of care and violates the client's autonomy and right to make decisions about their own treatment. This is an example of negligence as it goes against the ethical principle of informed consent. Choices A, B, and D do not meet the criteria for negligence as they involve actions taken in the best interest of the client, such as preventing harm or reporting concerning findings to the provider. In choice A, the nurse is trying to prevent harm by applying restraints to a client who is making a potentially harmful decision. In choice B, the nurse is identifying and reporting a concerning clinical finding promptly. In choice D, the nurse is attempting to educate the client and prevent harm related to dietary restrictions.