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A nurse is caring for a client who has named a person to serve as his health care proxy. The client states he needs clarification about this type of advance directive. Which of the following statements by the client indicates a need for clarification?
- A. The health care proxy does not go into effect until I am incapable of making decisions.
- B. I have to choose a family member as my health proxy.
- C. I can change who I designate as my health care proxy at any time.
- D. If I become incapacitated, end-of-life choices will be made by my proxy.
Correct Answer: B
Rationale: The correct answer is B: "I have to choose a family member as my health proxy." This statement indicates a need for clarification because it is incorrect. The client can choose any competent adult to be their health care proxy, not just a family member. This misconception may limit the client's options and understanding of their rights.
Incorrect choices:
A: This statement is correct as the health care proxy only goes into effect when the client is incapable of making decisions.
C: This statement is correct as the client can change their designated health care proxy at any time.
D: This statement is correct as the health care proxy will make end-of-life choices if the client becomes incapacitated.
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A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk?
- A. Handrails are present in the bathroom.
- B. Electrical cords are placed along the walls.
- C. Uses a microwave for cooking.
- D. Scatter rugs are present in the kitchen.
Correct Answer: D
Rationale: The correct answer is D: Scatter rugs are present in the kitchen. Scatter rugs can pose a safety risk for an older adult with decreased vision due to glaucoma as they increase the risk of tripping and falling. The uneven surface and lack of secure placement make scatter rugs hazardous. Handrails in the bathroom (A) enhance safety, electrical cords along the walls (B) may be a tripping hazard but can be easily addressed, and using a microwave for cooking (C) is a safe and convenient option for someone with decreased vision.
A nurse is caring for a client who is 1 day postoperative following a transsphenoidal hypophysectomy. While assessing the client, the nurse notes a large area of clear drainage seeping from the nasal packing. Which of the following should be the nurse’s initial action?
- A. Check the drainage for glucose.
- B. Notify the client’s provider.
- C. Document the amount of drainage.
- D. Obtain a culture of the drainage.
Correct Answer: A
Rationale: The correct initial action is to check the drainage for glucose (Choice A). This is crucial because clear drainage after a transsphenoidal hypophysectomy may indicate a cerebrospinal fluid leak, which can be confirmed by the presence of glucose in the drainage. If glucose is present, it suggests leakage of cerebrospinal fluid and requires immediate intervention to prevent complications such as infection and meningitis. The other options (B, C, and D) are not the most appropriate initial actions. Notifying the provider, documenting the amount of drainage, or obtaining a culture can be important steps but should come after confirming the presence of glucose to address the immediate concern of a potential cerebrospinal fluid leak.
A nurse is preparing a client who is postoperative following a below-the-knee amputation for a leg prosthesis fitting. Which of the following actions should the nurse take?
- A. Wrap the stump with an elastic bandage in a figure-eight configuration.
- B. Remove the elastic bandage and re-wrap the stump once per day.
- C. Perform passive range of motion exercises once daily.
- D. Secure the elastic bandage to the lowest joint.
Correct Answer: A
Rationale: The correct answer is A: Wrap the stump with an elastic bandage in a figure-eight configuration. This action helps reduce swelling, provide support, and shape the stump for prosthesis fitting. Wrapping in a figure-eight pattern ensures even compression and prevents constriction. Choice B is incorrect as frequent re-wrapping can disrupt wound healing. Choice C is unnecessary and may cause discomfort. Choice D is incorrect as securing the bandage at the lowest joint can lead to constriction and hinder circulation.
A nurse is assessing a client who has hypothyroidism. Which of the following findings should the nurse expect?
- A. Exophthalmos
- B. Photophobia
- C. Lethargy
- D. Weight loss
Correct Answer: C
Rationale: Rationale: Hypothyroidism is characterized by decreased thyroid hormone levels, leading to symptoms such as lethargy due to slowed metabolism. Exophthalmos (bulging eyes) is associated with hyperthyroidism. Photophobia (sensitivity to light) is not a common symptom of hypothyroidism. Weight loss is more indicative of hyperthyroidism due to increased metabolism. Therefore, the correct answer is C: Lethargy, as it aligns with the expected findings in hypothyroidism.
A nurse is caring for a client who has acute respiratory distress syndrome (ARDS) and requires mechanical ventilation. The client receives a prescription for pancuronium. The nurse recognizes that this medication is for which of the following purposes?
- A. Induce sedation.
- B. Suppress respiratory effort.
- C. Decrease chest wall compliance.
- D. Decrease respiratory secretions.
Correct Answer: B
Rationale: The correct answer is B: Suppress respiratory effort. Pancuronium is a neuromuscular blocking agent that paralyzes skeletal muscles, including the muscles involved in breathing. In ARDS, the client may have difficulty breathing due to lung damage, so pancuronium can be used to facilitate mechanical ventilation by preventing respiratory muscle movement. This allows the ventilator to control the client's breathing without interference. The other choices are incorrect because pancuronium does not induce sedation (A), affect chest wall compliance (C), or decrease respiratory secretions (D). It solely works to suppress respiratory effort by blocking neuromuscular transmission.