Nokea
An end-of-life client receiving home hospice care states he no longer wants to eat. The nurse should
- A. speak with the health care provider about inserting a feeding tube.
- B. encourage the client to eat small, nutritious meals.
- C. accept the client's decision and work to make the client comfortable.
- D. ask the client's family to bring the client's favorite foods.
Correct Answer: C
Rationale: In hospice care, respecting the client’s autonomy is key. Accepting the decision to stop eating and focusing on comfort aligns with end-of-life care principles.
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Which snack selection by a client with osteoporosis indicates that the client understands the dietary management of the disease?
- A. A granola bar
- B. A bran muffin
- C. Yogurt
- D. Raisins
Correct Answer: C
Rationale: Yogurt is rich in calcium, which is essential for bone health in osteoporosis management.
The nurse is caring for a client who has a lithium level of 2.2 mEq/L. Based on this lab value, what would the nurse anticipate to do in order to care for this client? Select all that apply.
- A. prepare to administer IV fluids
- B. notify the health care provider
- C. order a mechanical soft diet for the client
- D. administer the next dose of lithium when it is due
- E. observe the client for confusion and slurred speech
Correct Answer: A, B, E
Rationale: A lithium level of 2.2 mEq/L indicates toxicity (therapeutic range: 0.6–1.2 mEq/L). The nurse should prepare IV fluids, notify the provider, and monitor for symptoms like confusion and slurred speech. A soft diet is unnecessary, and the next dose should be held.
The nurse gives a 35-year-old primigravida client a RhoGAM injection in her 27th week of pregnancy. Which of the following client situations requires the nurse to take this action?
- A. Rh-negative mother and Rh-positive father
- B. Rh-negative mother and Rh-negative father
- C. Rh-positive mother and Rh-negative father
- D. Rh-positive mother and Rh-positive father
Correct Answer: A
Rationale: RhoGAM is given to an Rh-negative mother with an Rh-positive father to prevent Rh incompatibility issues in the fetus.
The physician prescribes regular insulin, 5 units subcutaneous. Regular insulin begins to exert an effect:
- A. In 5-10 minutes
- B. In 10-20 minutes
- C. In 30-60 minutes
- D. In 60-120 minutes
Correct Answer: C
Rationale: Regular insulin has an onset of 30-60 minutes when given subcutaneously.
The nurse is caring for a client admitted with congestive heart failure. Which finding would the nurse expect if the failure was on the right side of the heart?
- A. Jugular vein distention
- B. Dry, nonproductive cough
- C. Orthopnea
- D. Crackles on chest auscultation
Correct Answer: A
Rationale: Right-sided heart failure causes systemic venous congestion, leading to jugular vein distention, a hallmark sign of impaired right heart function.