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The client has decided to stop dialysis treatment.
A nurse is caring for a client who has end-stage kidney disease. The client has decided to stop dialysis treatment. Which of the following actions should the nurse take?
- A. Ask the facility chaplain to visit the client.
- B. Discuss alternative treatment methods with the client.
- C. Support the client's decision to stop the treatment.
- D. Tell the client she should discuss this decision with her family.
Correct Answer: C
Rationale: Supporting the client's decision respects autonomy, a fundamental ethical principle.
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A nurse is completing documentation in the medical record about a client who fell on the floor. Which of the following statements should the nurse include in the documentation?
- A. The client fell because the assistive personnel did not place nonskid slippers on the client.
- B. Client stated, 'I lost my balance and fell when I got out of bed to go to the bathroom.'
- C. An incident report has been completed and sent to risk management.
- D. The client does not appear to have any injuries resulting from the fall.
Correct Answer: B
Rationale: Quoting the client's statement provides an objective account of the event.
The child has ADHD and is taking methylphenidate.
A nurse is reinforcing teaching with the parents of a child who has ADHD and is taking methylphenidate. Which of the following statements by the parents indicates that the medication is effective?
- A. Our child has increased his daily caloric intake.
- B. Our child has a better grasp of reality.
- C. Our child has lost some weight since his last appointment.
- D. Our child is able to complete his homework on time.
Correct Answer: D
Rationale: Improved focus and task completion indicate methylphenidate's effectiveness.
A nurse is collecting data for a client who is receiving enteral tube feedings. The nurse should identify that which of the following findings is a manifestation of fluid overload?
- A. Decreased blood pressure
- B. Decreased skin turgor
- C. Weight loss
- D. Crackles heard in the lungs
Correct Answer: D
Rationale: Crackles in the lungs indicate fluid overload from excessive enteral feeding.
A nurse is assisting with a community health presentation about home safety precautions when there is an outdoor chemical disaster nearby. Which of the following instructions should the nurse include?
- A. Exit the home as quickly as possible.
- B. Turn on ceiling fans and air conditioners.
- C. Cover heat registers with plastic and tape.
- D. Open the dampers of fireplaces.
Correct Answer: C
Rationale: Covering heat registers prevents chemical entry indoors.
A nurse is caring for a client who has a prescription for NPH insulin 10 units and regular insulin 15 units subcutaneously. After injecting 10 units of air into the NPH insulin vial, which of the following actions should the nurse take next?
- A. Inject 15 units of air into the regular insulin vial.
- B. Withdraw 10 units of NPH insulin.
- C. Verify the dosage with another nurse.
- D. Place the cap over the needle.
Correct Answer: A
Rationale: Injecting air into the regular insulin vial next follows the correct sequence for mixing insulins.