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An older woman with end-stage heart disease is hospitalized for severe heart failure. She is alert and requests that no heroic measures be implemented if her breathing stops.What actions should the nurse take first?
- A. Obtain a do not resuscitate prescription.
- B. Set up a family conference to discuss the client's wishes.
- C. Discuss with the client her meaning of heroic measures.
- D. Consult the palliative care team about the client's care.
Correct Answer: C
Rationale: The nurse should first discuss with the client her meaning of heroic measures. This will help the nurse to understand the client's wishes and preferences for her care.
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The nurse is caring for a male client with decreased circulation in the lower extremities. The client washes his feet in the shower but is unable to bend safely to dry the feet.While drying the client's feet, the nurse should emphasize the need to thoroughly dry which area of the feet?
- A. On the dorsal surfaces.
- B. Between the toes.
- C. Over the heels.
- D. Around the ankles.
Correct Answer: B
Rationale: While drying the client's feet, the nurse should emphasize the need to thoroughly dry between the toes. Moisture between the toes can create a breeding ground for bacteria and fungi, which can lead to infections such as athlete's foot.
The nurse is planning to provide mouth care to an unconscious client.Which statement is accurate for implementing mouth care to this client?
- A. Brushing an unconscious client's teeth should be avoided.
- B. Cleaning the inner cheeks and outer gum surfaces with a gauze pad is appropriate for an unconscious client.
- C. Unconscious clients need less frequent mouth care than conscious clients.
- D. Positioning the unconscious client upright is the best method because they are not eating or drinking.
Correct Answer: B
Rationale: Cleaning the inner cheeks and outer gum surfaces with a gauze pad is appropriate for an unconscious client. When mouth care is provided, an unconscious patient is placed in the side-lying position because this prevents secretions from pooling at the back of the oral cavity, lowering the risk of aspiration.
The nurse is using guided imagery with a client who is experiencing chronic pain.What should the nurse direct the client's attention on during the session?
- A. Positive external places.
- B. Motivational phrases.
- C. Tranquil sounds.
- D. Emotional reflection.
Correct Answer: A
Rationale: Guided imagery involves creating a specific imagined reality for yourself. These techniques can be self-taught or guided by a professional. The more you're able to use your imagination and engage your senses, the greater the benefits.
The nurse is teaching a client how to do active range of motion (ROM) exercises.To exercise the hinge joints, which action should the nurse instruct the client to perform?
- A. Tap the feet forwards and backwards.
- B. Bend the arm by flexing the ulna to the humerus.
- C. Turn the head to the right and left.
- D. Extend the arm at the side and rotate in circles.
Correct Answer: B
Rationale: To exercise the hinge joints, the nurse should instruct the client to bend the arm by flexing the ulna to the humerus. Hinge joints allow for movement in one direction, like a door hinge. The elbow joint is an example of a hinge joint.
The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration.Which action by the UAP should the nurse recognize indicates the need for additional teaching?
- A. Places food on the unaffected side of the mouth.
- B. Raises the head of the bed to 80 degrees.
- C. Positions the head with the chin tilted slightly downward.
- D. Allows 30 minutes of rest before feeding.
Correct Answer: B
Rationale: Raising the head of the bed to 80 degrees is too high and can increase the risk of choking or aspiration by making it harder for the client to control the food bolus during swallowing. A more appropriate position is raising the head of the bed to 45–60 degrees, which facilitates safe swallowing while maintaining comfort.