Nokea
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. We should talk about your decision later.
- B. Your quality of life will be compromised if you make this decision.
- C. How will you discuss this decision with your loved ones?
- D. Don't worry. Everything will work out for you.
Correct Answer: C
Rationale: Asking about discussing the decision respects autonomy and encourages communication.
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A nurse is caring for a client who is postoperative and is preparing to walk for the first time in several days. Which of the following instructions should the nurse give the client to prevent orthostatic hypotension?
- A. Dangle your legs over the side of the bed.
- B. Use your incentive spirometer.
- C. Increase your intake of protein.
- D. Perform regular isometric exercises.
Correct Answer: A
Rationale: Dangling legs before standing allows gradual adjustment to upright posture, reducing orthostatic hypotension risk.
A nurse is providing end-of-life care to a client who is experiencing dyspnea. Which of the following actions should the nurse take?
- A. Reposition the client once every 4 hr.
- B. Provide oral care to the client once every 8 hr.
- C. Place the head of the client's bed flat.
- D. Use a fan to circulate air in the client's room.
Correct Answer: D
Rationale: A fan improves air movement, easing dyspnea in end-of-life care.
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: 5
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/day; 12.5 ÷ 4 = 3.125 mL, rounded to 5 mL.
A nurse is reinforcing teaching with a client who has crutches regarding the use of the three-point gait. Which of the following instructions should the nurse include?
- A. Stand with the crutch tips against the feet.
- B. Hold the arms straight when walking.
- C. Keep the crutches at the level of the axillae.
- D. Bear weight on the unaffected leg.
Correct Answer: D
Rationale: The three-point gait involves bearing weight on the unaffected leg while advancing crutches and the affected leg.
A nurse is caring for a client who has insomnia. Which of the following actions should the nurse take?
- A. Administer prescribed diuretics in the evening
- B. Provide the client with snug-fitting nightwear
- C. Keep the door to the client's room closed
- D. Use overhead lighting when checking equipment
Correct Answer: C
Rationale: Closing the door reduces noise, promoting sleep; other options may disrupt it.