Nokea
A nurse is preparing discharge planning for a client who has a newly placed tracheostomy tube. The nurse should assess the client's need for which of the following supplies to manage the tracheostomy at home?
- A. Pipe cleaners
- B. Oxygen tank
- C. Obturator
- D. Cotton balls
- E. Petroleum jelly
Correct Answer: B,C
Rationale: The correct answers are B and C. Option B, an oxygen tank, is essential for providing supplemental oxygen if the client experiences any respiratory distress at home. Option C, an obturator, is crucial for reinserting the tracheostomy tube if it accidentally dislodges.
Pipe cleaners (A) are not necessary for tracheostomy care. Cotton balls (D) can leave fibers behind and are not recommended. Petroleum jelly (E) can cause aspiration if applied near the stoma.
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A nurse is providing care for a client who has terminal cancer and is refusing chemotherapy. Which of the following actions should the nurse take?
- A. Request the client sign an informed consent.
- B. Encourage the client to reconsider their decision
- C. Communicate the client's decision to the provider.
- D. Provide care for the client using a sympathetic approach.
Correct Answer: C
Rationale: The correct answer is C: Communicate the client's decision to the provider. This is the most appropriate action as it ensures the client's wishes are respected while also involving the healthcare provider in the decision-making process. By communicating the client's decision, the nurse is upholding the client's autonomy and promoting patient-centered care. Option A is incorrect as the client's refusal of chemotherapy does not require informed consent. Option B is inappropriate as it undermines the client's autonomy by pressuring them to reconsider. Option D is not the best choice as it focuses on the nurse's approach rather than facilitating communication between the client and the provider.
A nurse is caring for a client who is unconscious and whose partner is their health care surrogate. The partner wishes to discontinue the client's feeding tube, but another family member tells the nurse that they want the client to continue receiving treatment. Which of the following responses should the nurse make?
- A. We'll need to have the nursing supervisor review the client's advance directives.
- B. As the health care surrogate, the client's partner can make this decision.
- C. You should contact the provider about your wishes for your family member.
- D. You should speak with the facility's ethics committee about your concerns.
Correct Answer: B
Rationale: The correct answer is B: As the health care surrogate, the client's partner can make this decision. The rationale for this is that a health care surrogate is legally designated to make medical decisions on behalf of an incapacitated individual. In this case, since the client is unconscious, the partner's wishes as the surrogate should be followed.
Choice A is incorrect because involving the nursing supervisor to review advance directives is not necessary when a designated surrogate is involved. Choice C is incorrect as contacting the provider is not relevant when the surrogate has the legal authority to make decisions. Choice D is also incorrect as involving the ethics committee is not necessary when a surrogate has the authority to make decisions.
The family members of an older adult client are expressing conflict over whether the client should have surgery that is recommended by the provider. The oldest adult child has durable power of attorney for health care for the client. The client is oriented to person, place, and time. Which of the following people has the legal authority to make this health care decision?
- A. The client
- B. The partner
- C. The provider
- D. The oldest adult child
Correct Answer: A
Rationale: A mentally competent client retains legal authority to make healthcare decisions, despite a durable power of attorney, which only applies when the client is incapacitated.
A nurse manager is reviewing isolation guidelines with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding of isolation guidelines?
- A. I will instruct visitors to wear a mask when visiting a client who is on contact precautions.
- B. I will have a client who is on airborne precautions wear a mask when out of her room.
- C. I will wear an N95 respirator mask when caring for a client who is on droplet precautions.
- D. I will place a client who has compromised immunity in a negative-pressure airflow room.
Correct Answer: B
Rationale: The correct answer is B because it demonstrates understanding of airborne precautions. Airborne precautions require clients to wear a mask when leaving their room to prevent the spread of infectious agents through the air. This statement aligns with the principle of protecting others from exposure.
Explanation for other choices:
A - Incorrect: Visitors, not clients, should wear masks on contact precautions to prevent the spread of infection to the client.
C - Incorrect: N95 respirator masks are used for airborne precautions, not droplet precautions.
D - Incorrect: Negative-pressure airflow rooms are used for clients on airborne precautions, not those with compromised immunity.
A pediatric nurse is caring for multiple clients and reviewing each of their care plans. Which of the following client care interventions requires revising?
- A. Teach an adolescent who has an exacerbation of ulcerative colitis about a high-protein, low fiber diet.
- B. Administer a bronchodilator two times a day for child who has cystic fibrosis.
- C. Check the neurovascular status every 4 hr of a child who had a hip spica cast placed 6 hr ago.
- D. Maintain eye shields for a newborn receiving phototherapy for hyperbilirubinemia.
Correct Answer: B
Rationale: Bronchodilators for cystic fibrosis are needed more frequently, typically before each chest physiotherapy session, requiring revision of the care plan.