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A nurse is caring for a client who has a terminal illness. The client asks what type of care will be provided as death approaches. Which of the following statements should the nurse make first?
- A. Tell me your expectations about activities related to the end-of-life.
- B. You can provide the name of a spiritual support person we can contact for you.
- C. You can allow your family to visit as often as you wish.
- D. We can talk to the provider about incorporating nonpharmacological pain management in your care.
Correct Answer: A
Rationale: Asking about expectations establishes a foundation for personalized end-of-life care planning.
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A nurse is caring for a client and observes a nurse from another unit reviewing the client's medical record. Which of the following actions should the nurse take?
- A. Tell the nurse that permission from the risk manager is required to view the client's record.
- B. Remind the nurse that only staff caring for the client may access the client's record.
- C. Complete an incident report about the breach of confidentiality.
- D. Contact facility security to remove the nurse from the unit.
Correct Answer: B
Rationale: Reminding about access rules upholds confidentiality standards.
A nurse is assisting with the care of a client who is experiencing dysphagia following a recent stroke. The nurse should initiate a referral to which of the following interprofessional team members?
- A. Occupational therapist
- B. Registered dietitian
- C. Respiratory therapist
- D. Speech-language pathologist
Correct Answer: D
Rationale: A speech-language pathologist is specifically trained to evaluate and treat swallowing disorders (dysphagia), which makes them the appropriate specialist for this referral.
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.
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 requires a sterile dressing change. The nurse should recognize that the surgical field has been contaminated if which of the following actions occur?
- A. The sterile solution is poured with the bottle held over the field.
- B. Unnecessary sterile items are placed on the field.
- C. A pair of sterile forceps is allowed to rest in a container of sterile water on the field.
- D. The handle of a pair of sterile scissors is resting 5 cm (2 in) from the field's edge.
Correct Answer: A
Rationale: Pouring solution with the bottle over the field risks contamination from touch or splash.