Nokea
An adult client is admitted with back pain and found to have a metastatic tumor on the spine. The health care provider (HCP) explains that the client has few months to live and is likely to become totally paralyzed below the waist soon. The next day, the client tells the nurse of wanting to be discharged despite the HCP's recommendation that the client stay a few more days. Which is the most appropriate initial response by the nurse?
- A. I understand your desire to leave, but it would be very risky.
- B. I will ask the palliative care nurse to talk with you to help clarify your care goals.
- C. I will let the HCP know that you want to be discharged and do everything I can to make it happen.
- D. Tell me more about your need to leave the hospital.
Correct Answer: D
Rationale: Exploring the client's reasons respects autonomy and facilitates understanding. Warning about risks may dismiss feelings, referring to palliative care is premature, and promising discharge bypasses collaboration.
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A client who is scheduled for surgery today says to the nurse, 'Do you think I'll survive the surgery?' What is the best initial response for the nurse to give?
- A. Don't worry, your surgeon is good.'
- B. Tell me about your concerns.'
- C. I can call your clergyman.'
- D. We do a lot of these surgeries here; everything will be okay.'
Correct Answer: B
Rationale: Exploring concerns validates the client's fears, fostering trust and addressing anxiety therapeutically.
The nurse is administering a cleansing enema to a client the night before bowel surgery. When administering the enema, the client reports cramping and pain. Which of the following actions should the nurse take?
- A. Slowly raise the height of the solution container
- B. Tell the client that the process will not take much longer
- C. Temporarily stop instilling the solution, then resume at a slower rate
- D. Withdraw the tube approximately 2 cm and continue the instillation
Correct Answer: C
Rationale: Pausing and slowing the flow reduces cramping by allowing the bowel to adjust. Raising the container increases pressure, reassurance doesn't address pain, and withdrawing the tube is unnecessary.
Which client incident would be classified as an adverse event that requires an incident/event/irregular occurrence/variance report? Select all that apply.
- A. Client admitted with WBC count of 28,000 mm3 (28.0 x 109/L) and dies from sepsis
- B. Client receives 1 mg morphine instead of prescribed 0.5 mg morphine
- C. Client refuses pneumonia vaccination and contracts pneumonia
- D. Nurse did not report client's new hemoglobin result of 6.0 g/dL (60 g/L) to oncoming nurse
- E. Provider was not notified of client's positive blood culture results
Correct Answer: B,D,E
Rationale: Medication error , failure to report hemoglobin , and failure to notify about blood culture are reportable adverse events. Sepsis death and vaccine refusal are not necessarily preventable errors.
An adult is admitted with a pneumothorax following an accident. Immediately after insertion of a chest tube, the client says to the nurse, 'Why do I have a tube in my chest and that thing hanging on the side of the bed? I don't like it.' What should the nurse include when replying to the client?
- A. Tell the client that the chest tube helps the client take bigger breaths
- B. Focus on the client's feelings
- C. Explain that the chest tube will remove air and/or fluid from the pleural cavity and allow the lung to reexpand
- D. Tell the client that the nurse will contact the physician to have it removed
Correct Answer: C
Rationale: The chest tube drains air/fluid from the pleural space, allowing lung re-expansion in pneumothorax, providing an accurate, educational response to the client's question.
The nurse is participating in staff training about protecting clients' privacy and confidentiality. Which of the following incidents does the nurse recognize as a violation of client confidentiality? Select all that apply.
- A. A visitor talking in the waiting room states that the client has alcoholism
- B. The licensed practical nurse (LPN) has the client's report sheet in a pocket when going home
- C. The nursing assistant tells a client that the hospital roommate went for a gallbladder test
- D. The registered nurse tells a visitor to wear a mask because the client is on isolation precautions
- E. Two LPNs are discussing a possible cure for AIDS on a crowded elevator
Correct Answer: A,B,C
Rationale: Visitor disclosure , taking reports home , and sharing roommate info violate confidentiality. Isolation precautions and general discussion do not.