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A nurse is caring for a client who has a terminal diagnosis and states, 'I am ready to update my will.' The nurse should identify that the client is experiencing which of the following Kubler-Ross stages of grief?
- A. Denial
- B. Acceptance
- C. Anger
- D. Bargaining
Correct Answer: B
Rationale: The correct answer is B: Acceptance. The client expressing readiness to update their will indicates acceptance, one of the stages of grief according to Kubler-Ross. This stage involves coming to terms with the reality of the situation and making necessary preparations. Denial (choice A) involves refusing to accept the diagnosis, anger (choice C) involves feelings of frustration and unfairness, and bargaining (choice D) involves seeking ways to avoid the inevitable. In this scenario, the client's statement aligns with the acceptance stage, as they are taking practical steps to prepare for the future.
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The nurse is caring for a client who has had partial removal of the parathyroid gland. The client reports numbness and tingling of the hands and fingers. Which lab value would the nurse expect to see?
- A. Chloride 112
- B. Calcium 7.5
- C. Potassium 4.0
- D. Calcium 12.1
Correct Answer: B
Rationale: The correct answer is B: Calcium 7.5. With partial removal of the parathyroid gland, there may be decreased production of parathyroid hormone leading to hypocalcemia. Numbness and tingling in the hands and fingers are classic symptoms of hypocalcemia. A low calcium level of 7.5 is indicative of this condition.
Choice A: Chloride 112 is not related to symptoms of numbness and tingling.
Choice C: Potassium 4.0 is within the normal range and not associated with symptoms of hypocalcemia.
Choice D: Calcium 12.1 indicates hypercalcemia, not hypocalcemia, which would not cause numbness and tingling.
A nurse is caring for a client who has a Penrose drain. Which of the following actions should the nurse take?
- A. Clean the skin near the drain in a circular motion from the outside to the inside
- B. Empty the drainage device when it is half full
- C. Place a perforated gauze pad around the drain to absorb drainage
- D. Connect the drain to continuous low-pressure suction
Correct Answer: C
Rationale: Rationale: Choice C is correct because placing a perforated gauze pad around the drain helps absorb drainage and prevents skin irritation. This promotes wound healing and prevents infection. Choice A is incorrect as it can introduce bacteria into the wound. Choice B is incorrect because drainage should be emptied when it reaches a certain level, not necessarily when it is half full. Choice D is incorrect as Penrose drains do not require suction.
A nurse is gathering evidence-based practice on catheter-associated urinary tract infections (CAUTI). Which of the following roles is the nurse performing?
- A. Researcher
- B. Nurse manager
- C. Case manager
- D. Educator
Correct Answer: A
Rationale: The correct answer is A: Researcher. The nurse is gathering evidence-based practice on CAUTI, which involves conducting research to gather relevant information, analyze data, and draw conclusions based on evidence. This role aligns with the responsibilities of a researcher who systematically investigates a topic to contribute to the body of knowledge. The other choices are incorrect because: B: Nurse managers oversee nursing staff and operations, C: Case managers coordinate patient care, and D: Educators focus on teaching and disseminating knowledge. In this scenario, the nurse's primary role is to gather evidence through research, making option A the most appropriate choice.
A nurse is assessing a client who has an oral temperature of 39 C (102.27 F). Which of the following findings should the nurse expect?
- A. Decreased peripheral pulses
- B. Heart rate 108/min
- C. Respiratory rate 10 breaths/min
- D. Dilated pupils
Correct Answer: B
Rationale: The correct answer is B: Heart rate 108/min. When a client has a fever (oral temperature of 39 C), the body responds by increasing the heart rate to help circulate blood more efficiently and maintain oxygen delivery to tissues. This compensatory mechanism is known as tachycardia. Decreased peripheral pulses (A) would not be expected as the body tries to increase circulation. Respiratory rate of 10 breaths/min (C) is extremely low and not consistent with fever. Dilated pupils (D) are not directly related to fever.
A nurse is preparing to lift a heavy object. Which of the following actions by the nurse indicates understanding of body mechanics?
- A. They bend at the hip when lifting
- B. They keep their feet together when lifting an object
- C. They stand close to the object being moved
- D. They twist their spine when lifting
Correct Answer: C
Rationale: The correct answer is C: They stand close to the object being moved. This action indicates understanding of body mechanics as it reduces the strain on the back by keeping the load close to the body's center of gravity. Standing close to the object allows for better leverage and control during the lift, minimizing the risk of injury.
Rationale for why other choices are incorrect:
A: Bending at the hip when lifting can put excessive strain on the lower back.
B: Keeping feet together may lead to instability and lack of balance during lifting.
D: Twisting the spine when lifting can result in spinal injuries and muscle strain.