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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. Don't worry. Everything will work out for you.
- B. Your quality of life will be compromised if you make this decision.
- C. We should talk about your decision later.
- D. How will you discuss this decision with your loved ones?
Correct Answer: D
Rationale: This response supports the client's autonomy and encourages communication.
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A nurse is assisting with feeding a client who has had a stroke. Which of the following findings should the nurse identify as a manifestation of dysphagia?
- A. Rapid chewing
- B. Increased hunger
- C. Garbled voice
- D. Sneezing
Correct Answer: C
Rationale: A garbled voice indicates swallowing difficulty, a sign of dysphagia.
A nurse is reinforcing teaching with an older adult client who has urinary incontinence. Which of the following instructions should the nurse include?
- A. Drink citrus juice with meals.
- B. Train the bladder by voiding every 5 hr.
- C. Perform pelvic-muscle exercises.
- D. Apply adult diapers at bedtime.
Correct Answer: C
Rationale: Pelvic-muscle exercises (Kegels) strengthen muscles to reduce incontinence.
A nurse is observing an assistive personnel (AP) apply a belt restraint to a client. Which of the following actions by the AP requires intervention by the nurse?
- A. Placing the restraint across the client's chest
- B. Applying the restraint over the client's gown
- C. Using a quick-release tie to secure the restraint
- D. Tying the restraint to the bed frame
Correct Answer: A
Rationale: Placing the restraint across the chest restricts breathing; it should be at the waist.
A nurse is caring for a client who had an indwelling urinary catheter inserted 3 days ago. Which of the following actions should the nurse take?
- A. Obtain urine from the drainage bag if a urinary specimen is required.
- B. Use a catheter securing device to hold the catheter in place.
- C. Change the catheter bag every 3 days and as needed.
- D. Position the drainage bag higher than the client's bladder.
Correct Answer: B
Rationale: A securing device prevents catheter movement and reduces infection risk.
A nurse is reinforcing teaching with a client about how to collect a stool specimen. Which of the following instructions should the nurse include?
- A. Urinate after the specimen collection.
- B. Place 1.3 cm (0.5 in) of formed stool into a culture tube.
- C. Keep the specimen in a warm area.
- D. Avoid placing toilet tissue in the bedpan after defecation.
Correct Answer: D
Rationale: Avoiding toilet tissue prevents contamination of the stool specimen.