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A nurse is caring for a client whose partner recently died. The nurse sits with the client to provide comfort. Which of the following ethical principles is the nurse demonstrating?
- A. Fidelity
- B. Veracity
- C. Autonomy
- D. Beneficence
Correct Answer: D
Rationale: The correct answer is D: Beneficence. Beneficence is the ethical principle that involves doing good and promoting the well-being of others. By sitting with the client to provide comfort after the loss of their partner, the nurse is demonstrating beneficence by showing compassion and support. Fidelity (A) relates to keeping promises and being faithful to commitments. Veracity (B) is about truthfulness and honesty. Autonomy (C) refers to respecting the client's right to make their own decisions. The other choices are not directly related to the nurse's action of providing comfort in this context.
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A nurse is planning teaching for a client and their family about home oxygen therapy.
Which of the following information should the nurse plan to include in the teaching?
- A. Apply petroleum jelly to soothe the mucous membranes
- B. Use synthetic fabrics for the client’s bedding
- C. Clean the equipment with an alcohol-based cleaning product.
- D. Avoid using nail polish remover around the client.
Correct Answer: D
Rationale: The correct answer is D: Avoid using nail polish remover around the client. This is important because nail polish remover contains harsh chemicals that can be harmful if inhaled or absorbed through the skin, especially for clients with compromised health conditions. Applying petroleum jelly (choice A) may not be recommended as it can trap bacteria and cause infection. Using synthetic fabrics for bedding (choice B) may not be ideal as natural fibers are more breathable and comfortable. Cleaning equipment with alcohol-based products (choice C) may not be suitable as it can be irritating to sensitive skin. Therefore, choice D is the best option for the client's safety and well-being.
A nurse is caring for a female client who requests a contraceptive diaphragm.
Which of the following actions should the nurse take first?
- A. Teach the client how to insert the diaphragm
- B. Document the client's level of understanding about potential adverse effects.
- C. Supervise return demonstration of diaphragm use
- D. Determine the client's knowledge about diaphragm use
Correct Answer: D
Rationale: Assessing the client’s current knowledge is the first step in patient education.
A nurse is caring for a client who reports xerostomia following radiation therapy to the mandible.
Which of the following is an appropriate action by the nurse?
- A. Suggest rinsing his mouth with an alcohol-based mouth wash
- B. Provide humidification of the room air.
- C. Offer the client saltine crackers between meals
- D. Instruct the client on the use of esophageal speech
Correct Answer: B
Rationale: The correct answer is B: Provide humidification of the room air. Humidification helps to moisturize the air, making it easier for the client to breathe, especially if they have dry mouth or throat. This can improve comfort and prevent irritation. Choice A is incorrect because alcohol-based mouthwash can further dry out the mouth. Choice C is incorrect as saltine crackers can exacerbate dry mouth. Choice D is incorrect as esophageal speech is not related to addressing dry mouth.
A nurse is caring for a client who has acute glomerulonephritis. Which of the following findings should the nurse expect?
- A. Polyuria
- B. Hypotension
- C. Weight loss
- D. Hematuria
Correct Answer: D
Rationale: The correct answer is D: Hematuria. In acute glomerulonephritis, there is inflammation of the glomeruli in the kidneys leading to blood in the urine. This is known as hematuria. Polyuria (choice A) is not typically seen in this condition as the kidneys are not able to effectively filter urine. Hypotension (choice B) is unlikely as fluid retention and hypertension are more common due to decreased kidney function. Weight loss (choice C) is not a common finding as the condition often leads to fluid retention. Therefore, hematuria is the most expected finding in acute glomerulonephritis.
A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 mL/hr. Which of the following interventions should the nurse anticipate?
- A. Initiate continuous bladder irrigation.
- B. Administer a fluid bolus
- C. Clamp the catheter tubing for 30 min.
- D. Obtain a urine specimen for culture and sensitive
Correct Answer: B
Rationale: The correct answer is B: Administer a fluid bolus. The dark yellow urine output at 25 mL/hr indicates concentrated urine and potential dehydration. Administering a fluid bolus would help improve hydration status and increase urine output. Continuous bladder irrigation (A) is not indicated as there is no indication of bladder obstruction. Clamping the catheter tubing (C) can lead to urinary retention and should not be done without a specific reason. Obtaining a urine specimen for culture (D) is important, but addressing the dehydration issue takes priority.