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A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, 'What would happen if I arrived at the emergency department and I had difficulty breathing?' Which of the following responses should the nurse make?
- A. We would consult the person appointed by your health care proxy to make decisions.
- B. We would give you oxygen through a tube in your nose.
- C. You would be unable to change your previous wishes about your care.
- D. We would insert a breathing tube while we evaluate your condition.
Correct Answer: A
Rationale: The correct answer is A: We would consult the person appointed by your health care proxy to make decisions. This response aligns with the client's living will and respects their wishes for declining resuscitation. By involving the designated health care proxy, the healthcare team ensures that decisions are made in accordance with the client's preferences.
Choice B is incorrect because providing oxygen through a tube does not address the client's concerns about declining resuscitation. Choice C is incorrect as it does not address the client's current situation or need for support in the emergency department. Choice D is incorrect as it goes against the client's expressed wishes in the living will. It is important to prioritize the client's autonomy and respect their decisions regarding end-of-life care.
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A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol?
- A. The client uses a wool blanket on their bed.
- B. The client identifies the location of the fire extinguisher.
- C. The client stores an oxygen tank in a secure outdoor shed.
- D. The client has a weekly inspection checklist for oxygen equipment.
Correct Answer: D
Rationale: The correct answer is D because a weekly inspection checklist for oxygen equipment ensures that the equipment is functioning properly and reduces the risk of potential hazards. Option A is incorrect because wool blankets can create static electricity, which is a fire hazard. Option B is not directly related to oxygen safety. Option C is incorrect as storing an oxygen tank in an outdoor shed may expose it to extreme temperatures or moisture.
A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
- A. Place a name tag on the body.
- B. Obtain the pronouncement of death from the provider.
- C. Remove tubes and indwelling lines.
- D. Wash the client's body.
- E. Ask the client's family members if they would like to view the body.
Correct Answer: B, E, C, D, A
Rationale: 1. Obtain the pronouncement of death from the provider (B): This is the first step to officially confirm the client's passing.
2. Ask the client's family members if they would like to view the body (E): Providing support to the family is crucial.
3. Remove tubes and indwelling lines (C): This step is necessary to prepare the body for respectful handling.
4. Wash the client's body (D): Maintaining dignity and cleanliness is important.
5. Place a name tag on the body (A): This ensures proper identification for all involved.
In summary, obtaining the pronouncement of death is the priority, followed by addressing the emotional needs of the family, preparing the body, and ensuring proper identification. Removing tubes and washing the body come before placing the name tag.
A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider?
- A. Sodium 130 mEq/L
- B. Creatinine 1.0 mg/dL
- C. Sodium 135 mEq/L
- D. Potassium 5.4 mEq/L
Correct Answer: A
Rationale: The correct answer is A: Sodium 130 mEq/L. A sodium level of 130 mEq/L is considered hyponatremia, which can indicate potential fluid imbalance or certain health conditions. The nurse should report this finding to the provider for further evaluation and intervention.
Choices B, C, and D fall within normal reference ranges for creatinine, sodium, and potassium levels, respectively. Therefore, they do not require immediate reporting.
In summary, the nurse should report a low sodium level (A) as it can be clinically significant, while the other choices are within normal limits and do not warrant immediate action.
A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management?
- A. I think I should take my pain medication more often
- B. since it is not controlling my pain.
- C. Breathing faster will help me keep my mind off of the pain.
- D. It might help me to listen to music while I'm lying in bed.
- E. I don't want to walk today because I have some pain.
Correct Answer: C
Rationale: The correct answer is C. The client's statement about breathing faster to keep their mind off the pain indicates understanding of distraction techniques taught preoperatively. This method helps manage pain perception. Choices A and B suggest incorrect self-medication adjustments. Choices D and E do not demonstrate understanding of pain management strategies.
A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make?
- A. I will return shortly after I document this in your record.
- B. Most men live a long time with prostate cancer.
- C. I am available to talk if you should change your mind.
- D. I will make a referral to a cancer support group for you.
Correct Answer: C
Rationale: The correct answer is C: "I am available to talk if you should change your mind." This response shows the nurse's willingness to provide support and maintain an open line of communication without being intrusive. It respects the client's current decision while also conveying availability for future discussions, promoting trust and rapport.
A: Incorrect. This response prioritizes documentation over the client's emotional needs.
B: Incorrect. While well-intentioned, this statement may offer false reassurance and overlooks individual variability in prognosis.
D: Incorrect. Referring to a support group without the client's consent may not align with their current preferences.
E: Incorrect. Incomplete choice.
F: Incorrect. Incomplete choice.
G: Incorrect. Incomplete choice.