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A nurse is preparing to discharge a client who has end-stage heart failure. The client's partner tells the nurse she can no longer handle caring for the client. Which of the following actions should the nurse take?
- A. Contact the case manager to discuss discharge options.
- B. Request another family member assist the client's partner with care.
- C. Ask the provider to delay the client's discharge home for a few more days.
- D. Recommend the partner place the client in a long-term care facility.
Correct Answer: A
Rationale: A case manager can explore alternative care options, such as home health or facility placement, to support the client and partner.
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A nurse is caring for a client who has uterine prolapse. The provider has recommended a total abdominal hysterectomy, but the client tells the nurse that the surgery is not an option. Which of the following is an appropriate action for the nurse to take?
- A. Discuss with the client her concerns regarding the procedure.
- B. Initiate a mental health consult to determine the client's reasons for refusing surgery.
- C. Provide the client with information on treatment options and outcomes.
- D. Inform the client of the consequences of uterine prolapse and the need for intervention.
Correct Answer: A
Rationale: Correct Answer: A: Discuss with the client her concerns regarding the procedure.
Rationale:
1. Building Trust: By discussing the client's concerns, the nurse shows empathy and builds trust.
2. Client Autonomy: Respecting the client's decision-making process is essential.
3. Informed Decision-Making: Understanding the client's fears helps in providing tailored information.
4. Collaboration: Discussing concerns opens the door for shared decision-making.
5. Holistic Care: Addressing emotional aspects is crucial for overall well-being.
Incorrect Choices:
- B: Initiating a mental health consult may be premature and could undermine the client's autonomy.
- C: Providing information without addressing concerns may not address the root of the refusal.
- D: Informing the client without understanding her perspective may lead to increased anxiety and resistance.
A nurse is conducting an in-service on client advocacy with a group of newly licensed nurses. Which of the following scenarios should the nurse include as examples of client advocacy?
- A. Implementing a client's plan of care based upon nursing goals
- B. Obtaining an interpreter for a client who speaks a different language than the nurse
- C. Documenting a client's refusal to take a prescribed medication
- D. Initiating IV access on a client who has dementia while he is sleeping
- E. Providing written information to a client regarding palliative care
Correct Answer: B,C,E
Rationale: The correct scenarios for client advocacy are B: Obtaining an interpreter for a client who speaks a different language than the nurse, C: Documenting a client's refusal to take a prescribed medication, and E: Providing written information to a client regarding palliative care.
B is correct as it ensures effective communication, promoting the client's understanding and autonomy. C is essential for respecting the client's right to make decisions about their care. E demonstrates advocacy by empowering the client with information about their care options.
A is incorrect as it focuses on the nurse's goals rather than the client's needs. D is inappropriate as it violates the client's rights by performing a procedure without consent.
In summary, client advocacy involves respecting autonomy, ensuring effective communication, and providing information to empower the client in decision-making.
A nurse is serving on a committee whose task is to plan cost-effective care at the facility. Which of the following client care tasks should the nurse recommend?
- A. Change total parenteral nutrition IV tubing every 48 hr.
- B. Replace total parenteral nutrition solution bags every 48 hr.
- C. Replace peripheral IV solution bags every 96 hr.
- D. Change peripheral IV primary tubing every 96 hr.
Correct Answer: D
Rationale: The correct answer is D: Change peripheral IV primary tubing every 96 hr. This recommendation aligns with evidence-based practice guidelines for preventing infection risk associated with IV therapy. Changing the peripheral IV tubing every 96 hours helps reduce the risk of contamination and infection. Choice A is incorrect because changing total parenteral nutrition IV tubing every 48 hours is not necessary unless there is a specific indication. Choice B is incorrect as replacing total parenteral nutrition solution bags every 48 hours is not a standard practice and can lead to wastage. Choice C is incorrect because changing peripheral IV solution bags every 96 hours is less critical than changing the primary tubing.
A nurse is triaging a group of clients following a disaster. Which of the following clients should the nurse recommend for treatment first?
- A. A client who has a neck injury and is unable to breathe spontaneously
- B. A client who has bipolar disorder and is exhibiting signs of hallucination
- C. A client who has two open chest wounds with a left tracheal deviation
- D. A client who has major burns over 75% of her body surface area
Correct Answer: A
Rationale: A neck injury causing inability to breathe spontaneously is an immediate airway threat, prioritizing it per the ABCs of basic life support.
A nurse is preparing a client for surgery. The client expresses concern that someone might steal her purse during the procedure. Which of the following actions should the nurse take?
- A. Offer to store the purse at the nurses' station.
- B. Tell the client to leave her purse in a drawer of the bedside table.
- C. Place the purse in the clothing bag with the client's other belongings.
- D. Offer to place the purse in the facility safe.
Correct Answer: D
Rationale: The correct answer is D: Offer to place the purse in the facility safe. This is the best option as it ensures the client's belongings are kept secure during the surgery. Storing the purse at the nurses' station (A) may not guarantee its safety. Leaving the purse in a drawer (B) or clothing bag (C) can also pose a risk of theft. Placing it in the facility safe (D) is the most secure and professional solution to address the client's concern.