Nokea
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. We can talk to the provider about incorporating nonpharmacological pain management in your care.
- B. Tell me your expectations about activities related to the end-of-life.
- C. You can allow your family to visit as often as you wish.
- D. You can provide the name of a spiritual support person we can contact for you.
Correct Answer: B
Rationale: Exploring the client's expectations first ensures care aligns with their wishes.
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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. Garbled voice
- C. Sneezing
- D. Increased hunger
Correct Answer: B
Rationale: A garbled voice post-stroke indicates swallowing difficulty, a dysphagia sign.
A charge nurse on a long-term care unit is working with an assistive personnel who states, 'I am tired of all the changes on this unit. If things don't improve soon, I'm requesting a transfer.' Which of the following responses should the charge nurse make?
- A. Why don't you just file a formal complaint with Human Resources?
- B. Please, try to wait a little longer. Things will get better soon.
- C. There has been too much complaining about these changes.
- D. So, you are upset about all of the recent changes on the unit?
Correct Answer: D
Rationale: Reflecting the AP's feelings fosters communication and addresses concerns constructively.
A nurse is caring for an adult client who has a developmental disability. The client requires an emergency appendectomy, and the staff cannot reach the appointed guardian. Which of the following is an appropriate action for the nurse to take?
- A. Obtain consent from the client.
- B. Request that the provider sign the consent form.
- C. Postpone the procedure until the staff contacts the guardian.
- D. Prepare the client for surgery with implied consent.
Correct Answer: D
Rationale: Implied consent applies in emergencies when the guardian is unavailable, allowing life-saving treatment.
A nurse on a medical-surgical unit is caring for a postoperative client who reports difficulty sleeping due to noise. Which of the following interventions is appropriate for the nurse to implement?
- A. Conduct staff communications away from the client's room.
- B. Turn off alarms on bedside monitoring equipment.
- C. Avoid entering the client's room unless requested during the night.
- D. Turn on the client's TV to distract from hallway noise.
Correct Answer: A
Rationale: Reducing noise by moving staff communication away enhances sleep without compromising safety.
A nurse is preparing to administer medications to a client. Which of the following pieces of information should the nurse use as a client identifier?
- A. Room number
- B. Medical diagnosis
- C. Photograph
- D. Age
Correct Answer: C
Rationale: A photograph is a reliable identifier per safety standards, unlike room number or age.