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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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The nurse is reinforcing postpartum discharge instructions to a client. Which instruction should the nurse include to promote newborn safety?
- A. Avoid using blankets to position the newborn in the car seat
- B. Place the newborn in the prone position in bed while sleeping
- C. Position the newborn's car seat in the back seat facing forward
- D. Remove pillows and loose blankets from the newborn's crib
Correct Answer: D
Rationale: Removing pillows and blankets from the crib reduces SIDS risk. Blankets in car seats are unsafe, prone sleeping increases SIDS risk, and forward-facing car seats are incorrect for newborns.
The nurse has taught the parents of a 6-year-old client with cystic fibrosis who has a prescription for pancreatic enzymes. Which of the following statements by a parent would require follow-up?
- A. It is acceptable for my child to chew the medication before swallowing it
- B. I should give the medication with or just before my child has a meal or snack
- C. I need to monitor the total amount of medication that I give to my child every day.
- D. It is acceptable to open the capsule and sprinkle the medication on a tablespoon of applesauce.
Correct Answer: A
Rationale: Chewing pancreatic enzymes destroys the enteric coating, reducing efficacy. Timing with meals , monitoring doses , and sprinkling on applesauce are correct practices.
The most common reason for an Apgar score of 8 and 9 in a newborn is an abnormality of what parameter?
- A. Heart rate
- B. Muscle tone
- C. Cry
- D. Color
Correct Answer: D
Rationale: Color. Acrocyanosis (blue hands and feet) is the most common Apgar score deduction, and is a normal adaptation in the newborn.
A new nurse manager is seeking a mentor in the administrative realm. Which of these characteristics is a priority for the outcome of a positive experience with a mentor?
- A. Information is clarified as needed
- B. A teacher-coach role is taken by the mentor
- C. The mentee accepts feedback objectively
- D. The mentor is randomly assigned by administration
Correct Answer: B
Rationale: A teacher-coach role is taken by the mentor. A mentor who guides and coaches fosters a productive learning experience.
A nurse at outpatient clinic is returning phone calls that have been made to the clinic. Which of the following calls should have the highest priority for medical intervention?
- A. A home health patient reports, 'I am starting to have breakdown of my heels.'
- B. A patient that received an upper extremity cast yesterday reports, 'I can't feel my fingers in my right hand today.'
- C. A young female reports, 'I think I sprained my ankle about 2 weeks ago.'
- D. A middle-aged patient reports, 'My knee is still hurting from the TKR.'
Correct Answer: B
Rationale: The patient experiencing neurovascular changes should have the highest priority. Pain following a TKR is normal, and breakdown over the heels is a gradual process. Moreover, a subacute ankle sprain is almost never a medical emergency.