Nokea
An alert adult who has terminal cancer says to the home care nurse, 'When the time comes for me to go, I don't want to be in pain and I don't want you to try to resuscitate me. Please promise me you won't.' How should the nurse respond?
- A. Of course, I will do as you wish.
- B. I am obligated to try and preserve life.
- C. Do you have advance directives? These need to be in your record.
- D. Be sure to tell each nurse your desires.
Correct Answer: C
Rationale: Asking about advance directives ensures the client's wishes are documented and legally binding, facilitating appropriate end-of-life care.
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A woman who was recently diagnosed with multiple myeloma says to the nurse, 'Why did this happen to me? I've always been a good person. What did I do to deserve this?' What should the nurse do initially?
- A. Remind the client that she is not dying now and has some time left
- B. Call the chaplain to discuss why it happened to her
- C. Respond by recognizing how difficult this situation must be
- D. Tell her she didn't do anything to deserve it
Correct Answer: C
Rationale: Acknowledging the client's emotional distress validates her feelings, fostering therapeutic communication. Other responses dismiss or redirect her concerns.
The nurse has just received report from the previous shift.
Which of the following patients should the nurse see FIRST?
- A. A patient who had coronary artery bypass graft (CABG) and will have the atrioventricular (AV) wires removed later in the day.
- B. A patient with type I diabetes who is scheduled for a cardiac catheterization later today.
- C. A patient who is one-day postoperative and has an epidural catheter in place.
- D. A patient who is being evaluated for a heart transplant.
Correct Answer: C
Rationale: Strategy: Determine which patient is the least stable. (1) although the patient requires a high level of nursing care, no indication that the patient is unstable (2) patient requires preoperative assessment and teaching, no indication that the patient is unstable (3) correct-epidural used for pain relief, monitor for urinary incontinence, hypotension, respiratory depression, and nausea and vomiting (4) requires monitoring but patient with epidural takes priority
The nurse is caring for a client with a history of depression who is receiving sertraline (Zoloft) 50 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
- A. I feel tired all the time.
- B. I have trouble sleeping at night.
- C. I think about hurting myself sometimes.
- D. I have a dry mouth.
Correct Answer: C
Rationale: Thoughts of self-harm indicate suicidal ideation, a medical emergency requiring immediate intervention in a client on sertraline. Options A, B, and D are common side effects of SSRIs (fatigue, insomnia, dry mouth) and less urgent.
The nurse knows that which psychosocial stage should be a priority to consider while planning care for a 20-year-old client?
- A. Identity versus identity diffusion.
- B. Intimacy versus isolation.
- C. Integrity versus despair and disgust.
- D. Industry versus inferiority.
Correct Answer: B
Rationale: is the stage for 19- to 35-year-olds
During administration of oral medications to an elderly, confused client, the client states, 'These pills look funny. They belong to the lady down the hall.' Which of the following is the BEST response by the nurse?
- A. Your physician has ordered new medications for you. They will help you get well.
- B. Remember yesterday when I brought your medications? They look the same.
- C. I'll explain why you are receiving these medications.
- D. I'll be back after I check your medications again.
Correct Answer: D
Rationale: Rechecking medications ensures safety, addressing the client’s concern about a possible error. Options A, B, and C risk administering incorrect drugs.