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A nurse is assisting with the care of a client who has cancer that has metastasized. The client has decided to discontinue chemotherapy treatment. Which of the following responses should the nurse make?
- A. Your quality of life will be compromised if you make this decision.
- B. How will you discuss this decision with your loved ones?
- C. Don't worry. Everything will work out for you.
- D. We should talk about your decision later.
Correct Answer: B
Rationale: Encouraging discussion with loved ones shows empathy and supports the client's autonomy.
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A nurse is reinforcing teaching with a client about using guided imagery to manage chronic pain. Which of the following statements by the client indicates an understanding of this technique?
- A. I'll use focused breathing to control my pain.
- B. I'll learn to notice the sensation of muscle tension.
- C. I think about my grandfather's farm to reduce pain.
- D. I listen to my favorite music to take my mind off the pain.
Correct Answer: C
Rationale: Guided imagery involves visualizing a calming scene like a farm to distract from pain.
A nurse is caring for a client who is postpartum. Which of the following documentations should the nurse include in the client's health record?
- A. Client instructed on self-care needs.
- B. Episiotomy approximated. 3 cm (1.18 in) in length.
- C. Client drank adequate amounts of fluid with meals.
- D. Oral temperature elevated at 0800.
Correct Answer: B
Rationale: Documenting the status of the episiotomy provides essential information regarding healing and recovery, a priority in postpartum care.
A nurse is collecting data from a client about bowel elimination. Which of the following statements by the client indicates a risk for impaired bowel elimination?
- A. I drink two hot cups of coffee each morning.
- B. I take a prescribed opioid pain medication at bedtime.
- C. I love to eat apples and black-eyed peas.
- D. I drink an average of 2,000 milliliters of water daily.
Correct Answer: B
Rationale: Opioids slow bowel motility, increasing constipation risk.
A nurse is preparing to administer ampicillin to a school-age child who weighs 55 lb. The provider prescribes 50 mg/kg/day in 4 equal doses. Available is ampicillin oral suspension 125 mg/5 mL. How many mL should the nurse administer with each dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 12.5 mL
Rationale: 55 lb = 25 kg; 50 mg/kg/day = 1250 mg/day; 1250 mg / 4 doses = 312.5 mg/dose; 312.5 mg / (125 mg/5 mL) = 12.5 mL/dose.
A nurse is wearing sterile gloves in preparation for assisting with a client's sterile procedure. While waiting for the procedure to begin, how should the nurse position their hands?
- A. Clasp their hands together in a relaxed position behind their body at their waist.
- B. Interlock their fingers and hold their hands away from their body above their waist.
- C. Keep their arms at the sides of their body with their hands in a relaxed position.
- D. Place one hand over the other against the part of the gown covering their upper body.
Correct Answer: B
Rationale: Interlocking fingers above the waist prevents glove contamination.