Nokea
A nurse is caring for a client who is about to undergo exploratory surgery to remove a malignant tumor and to determine the extent of any metastasis. The client tells the nurse that she is not hopeful that she will recover and begins to cry. Which of the following responses should the nurse make?
- A. Reassure the client that the provider will use advanced medical knowledge to treat any further problems with her tumor.
- B. Sit quietly with the client and follow her cues.
- C. Suggest that the client discuss her fears with the provider.
- D. Gently change the subject to something more positive.
Correct Answer: B
Rationale: Providing silent support and allowing the client to express emotions promotes emotional well-being.
You may also like to solve these questions
A nurse is reviewing blood pressure classifications with a client who has been newly diagnosed with hypertension. Which of the following should the nurse include as an example of stage 1 hypertension?
- A. 108/60 mm Hg
- B. 128/88 mm Hg
- C. 154/96 mm Hg
- D. 164/104 mm Hg
Correct Answer: C
Rationale: The correct answer is C (154/96 mm Hg) for stage 1 hypertension. Stage 1 hypertension is defined as systolic blood pressure ranging from 130-139 mm Hg or diastolic blood pressure ranging from 80-89 mm Hg. Option C falls within this range, making it the correct choice. Option A (108/60 mm Hg) is normal blood pressure. Option B (128/88 mm Hg) is prehypertension. Option D (164/104 mm Hg) falls within the stage 2 hypertension range, which is higher than stage 1 hypertension.
A nurse is assisting with the implementation of a bowel training program for a client. For the program to be effective, the nurse should take the client to the bathroom at which of the following times?
- A. When the client has the urge to defecate
- B. Every 2 hr while the patient is awake
- C. Immediately before meals
- D. After the client feels abdominal cramping
Correct Answer: A
Rationale: The correct answer is A: When the client has the urge to defecate. This is crucial for a successful bowel training program because it helps the client establish a regular bowel routine and strengthens the mind-body connection for recognizing the urge to defecate. Taking the client to the bathroom when they feel the urge also promotes independence and empowers the client to listen to their body's signals.
Choice B (Every 2 hr while the patient is awake) is incorrect because it does not align with the principles of bowel training, which focuses on responding to the body's natural signals. Choice C (Immediately before meals) is incorrect as the timing is not based on the client's physiological cues. Choice D (After the client feels abdominal cramping) is incorrect because waiting for abdominal cramping can lead to discomfort and is not proactive in managing bowel movements.
A nurse is measuring the vital signs of a client he suspects has hypovolemic shock. Which of the following findings should the nurse expect?
- A. High BP and low pulse rate
- B. Low BP and low pulse rate
- C. High BP and high pulse rate
- D. Low BP and high pulse rate
Correct Answer: D
Rationale: Hypovolemic shock leads to decreased blood pressure due to fluid loss and compensatory tachycardia.
A nurse is preparing to insert an indwelling urinary catheter for a female client. After opening the catheter kit and preparing the supplies, which of the following steps should the nurse perform next?
- A. Cleanse the meatus.
- B. Don sterile gloves.
- C. Cleanse the labia.
- D. Lubricate the catheter.
Correct Answer: B
Rationale: The correct next step is to don sterile gloves (choice B). This is essential to maintain aseptic technique and prevent infection during catheter insertion. Sterile gloves create a barrier between the nurse's hands and the client's urinary tract, reducing the risk of introducing pathogens. Cleansing the meatus (choice A) or labia (choice C) should come after donning sterile gloves to prevent contamination. Lubricating the catheter (choice D) should be done just before insertion to facilitate a smooth and comfortable procedure.
A nurse in a long-term care facility sees a client who is choking. Which of the following data should the nurse identify as requiring an abdominal thrust?
- A. The client is grasping his abdomen
- B. The client is hyperventilating
- C. The client is coughing
- D. The client cannot speak
Correct Answer: D
Rationale: Inability to speak is a sign of complete airway obstruction requiring abdominal thrusts. Coughing indicates partial obstruction and does not require immediate thrusts.