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A nurse is caring for a client who has a new diagnosis of Crohn's disease and is interested in learning more about their condition. Which of the following actions should the nurse take?
- A. Encourage the client to research Crohn's disease on websites that have a gov address.
- B. Ask a licensed practical nurse to explain Crohn's disease to the client.
- C. Recommend podcasts that discuss Crohn's disease to the client.
- D. Suggest that the client read articles that recommend specific treatments for Crohn's disease.
Correct Answer: A
Rationale: The correct answer is A: Encourage the client to research Crohn's disease on websites that have a gov address. This option is the most appropriate because government websites provide reliable and evidence-based information on medical conditions. The client can access accurate and up-to-date information to better understand their condition.
Choice B is incorrect because a licensed practical nurse may not have the same level of expertise and resources as a government website. Choice C is incorrect as podcasts may not always provide detailed and accurate information. Choice D is incorrect because reading articles recommending specific treatments may not provide a comprehensive understanding of the disease itself. It is important for the client to have a solid foundation of knowledge about Crohn's disease before delving into treatment options.
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A pediatric nurse is caring for multiple clients and reviewing each of their care plans. Which of the following client care interventions requires revising?
- A. Teach an adolescent who has an exacerbation of ulcerative colitis about a high-protein, low fiber diet.
- B. Administer a bronchodilator two times a day for child who has cystic fibrosis.
- C. Check the neurovascular status every 4 hr of a child who had a hip spica cast placed 6 hr ago.
- D. Maintain eye shields for a newborn receiving phototherapy for hyperbilirubinemia.
Correct Answer: B
Rationale: Bronchodilators for cystic fibrosis are needed more frequently, typically before each chest physiotherapy session, requiring revision of the care plan.
A nurse is caring for a client who is unconscious and whose partner is their health care surrogate. The partner wishes to discontinue the client's feeding tube, but another family member tells the nurse that they want the client to continue receiving treatment. Which of the following responses should the nurse make?
- A. We'll need to have the nursing supervisor review the client's advance directives.
- B. As the health care surrogate, the client's partner can make this decision.
- C. You should contact the provider about your wishes for your family member.
- D. You should speak with the facility's ethics committee about your concerns.
Correct Answer: B
Rationale: The correct answer is B: As the health care surrogate, the client's partner can make this decision. The rationale for this is that a health care surrogate is legally designated to make medical decisions on behalf of an incapacitated individual. In this case, since the client is unconscious, the partner's wishes as the surrogate should be followed.
Choice A is incorrect because involving the nursing supervisor to review advance directives is not necessary when a designated surrogate is involved. Choice C is incorrect as contacting the provider is not relevant when the surrogate has the legal authority to make decisions. Choice D is also incorrect as involving the ethics committee is not necessary when a surrogate has the authority to make decisions.
A client scheduled for a tubal ligation procedure starts to cry as she is wheeled into the surgical suite. Which of the following nursing statements is an appropriate nursing response?
- A. It's not too late to cancel the surgery if you want to.
- B. This won't take long and it will be over before you know it.
- C. Why did you make the decision to have this procedure?
- D. You shouldn't be worried because the procedure is very safe.
Correct Answer: A
Rationale: Correct Answer: A. "It's not too late to cancel the surgery if you want to."
Rationale: This response acknowledges the client's emotions and empowers her to make a decision based on her feelings. It shows empathy and respect for her autonomy in making choices about her own body.
Summary of Other Choices:
B: This response dismisses the client's emotions and may come off as insensitive.
C: Asking why the client made the decision can be perceived as judgmental and may increase anxiety.
D: This response invalidates the client's feelings and may not provide reassurance effectively.
A nurse on a medical-surgical unit is delegating client care. Which of the following tasks should the nurse delegate to assistive personnel?
- A. Instructing a client on self-administration of a tap water enema
- B. Suctioning a client's long-term tracheostomy
- C. Performing a dressing change on a client's peripherally inserted central catheter
- D. Using a pain rating scale to monitor a client's pain level
Correct Answer: D
Rationale: The correct answer is D: Using a pain rating scale to monitor a client's pain level. This task can be safely delegated to assistive personnel as it involves non-invasive monitoring that does not require specialized medical knowledge. Assistive personnel can accurately record the pain level reported by the patient without interpreting or making clinical decisions based on the information. In contrast, choices A, B, and C involve invasive procedures or specialized skills that require clinical judgment and assessment, making them inappropriate for delegation to assistive personnel. Choice D allows the nurse to focus on more complex nursing assessments and interventions while ensuring the client's pain is monitored effectively.
A charge nurse notices that two staff nurses are not taking meal breaks during their shifts. Which of the following actions should the nurse take first?
- A. Determine the reasons the nurses are not taking scheduled breaks.
- B. Provide coverage for the nurses' breaks.
- C. Review facility policies for taking scheduled breaks.
- D. Discuss time management strategies with the nurses.
Correct Answer: A
Rationale: Determining the reasons for not taking breaks identifies the root cause, enabling targeted solutions to ensure staff well-being.