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During an admission assessment, a nurse is documenting a client's medication. Which of the following actions should the nurse take?
- A. Counsel the client on medication adherence.
- B. Assess the client for medication reactions.
- C. Compile a list of the client's current medications.
- D. Evaluate the client's understanding of medications.
Correct Answer: C
Rationale: During an admission assessment, compiling a list of the client's current medications is crucial for accurate documentation and planning. This information helps prevent medication errors, identify potential interactions, and ensure continuity of care. While counseling the client on medication adherence (Choice A) is important, it is not the primary action when documenting medications. Assessing the client for medication reactions (Choice B) is relevant for monitoring side effects but not the immediate focus during documentation. Evaluating the client's understanding of medications (Choice D) is essential for education but does not address the immediate need for compiling a list of current medications.
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A nurse is collecting data from an older adult client as part of a neurologic examination. Which of the following findings should the nurse expect as changes associated with aging?
- A. Slower light touch sensation
- B. Some vision and hearing decline
- C. Slower fine finger movement
- D. Some short-term memory decline
Correct Answer: B
Rationale: As individuals age, it is common to experience changes in vision and hearing, leading to some decline in these senses. Slower light touch sensation and slower fine finger movement are also typical findings associated with aging. However, some short-term memory decline is more closely related to cognitive aging rather than typical age-related changes in the neurologic system. Therefore, the correct answer is the decline in vision and hearing. Decreased risk of depression is not a typical finding in aging; in fact, the risk of depression may increase as individuals age.
A client is receiving morphine via PCA infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device?
- A. I'll wait to use the device until it's absolutely necessary.
- B. I'll be careful about pushing the button too much to avoid an overdose.
- C. I should tell the nurse if the pain doesn't stop while I am using this device.
- D. I will ask my adult child to push the dose button when I am sleeping.
Correct Answer: C
Rationale: Choice C is the correct answer because it demonstrates that the client understands the importance of communicating with the nurse if the pain persists while using the PCA device. This is crucial as it ensures proper pain management and monitoring. Choices A and B are incorrect because delaying the use of the device until necessary or being cautious about pushing the button too much do not necessarily reflect understanding of using the PCA device effectively. Choice D is incorrect as having someone else, like an adult child, push the dose button goes against the principle of the client self-administering the medication through the PCA device.
The nurse is caring for a client with a newly placed colostomy. Which statement by the client indicates a need for additional teaching?
- A. I will need to change the colostomy bag every day.
- B. I should avoid foods that can cause gas, such as beans and carbonated drinks.
- C. I need to empty the colostomy bag when it is one-third to one-half full.
- D. I will need to take care of the skin around the stoma to prevent irritation.
Correct Answer: A
Rationale: The correct answer is A. Changing the colostomy bag every day is not necessary; it should be changed as needed, usually every 3-7 days. This statement indicates a need for additional teaching as frequent changes can irritate the skin and are not typically required. Choices B, C, and D are all correct statements regarding colostomy care. Avoiding gas-producing foods, emptying the bag when it is one-third to one-half full, and taking care of the skin around the stoma are all essential aspects of colostomy care to prevent complications and maintain skin integrity.
Following change-of-shift report on an orthopedic unit, which client should the nurse see first?
- A. 16-year-old who had an open reduction of a fractured wrist 10 hours ago
- B. 20-year-old in skeletal traction for 2 weeks since a motorcycle accident
- C. 72-year-old recovering from surgery after a hip replacement 2 hours ago
- D. 75-year-old who is in skin traction prior to planned hip pinning surgery
Correct Answer: C
Rationale: The 72-year-old recovering from surgery after a hip replacement 2 hours ago should be seen first due to the potential for immediate post-operative complications. This patient is in the immediate postoperative period and requires close monitoring for any signs of complications such as bleeding, infection, or impaired circulation. The other patients are relatively stable compared to the patient who just had surgery and therefore can wait for assessment and care without immediate risk. The 16-year-old had surgery ten hours ago, which is longer than the 72-year-old and is at a lower risk for immediate complications. The 20-year-old in skeletal traction for two weeks is stable in his current condition. The 75-year-old in skin traction before planned surgery does not require immediate attention as the surgery has not yet taken place.
When a client decides not to have surgery despite significant blockages of the coronary arteries, it is an example of which of the following ethical principles?
- A. Fidelity
- B. Autonomy
- C. Justice
- D. Nonmaleficence
Correct Answer: B
Rationale: The correct answer is autonomy. Autonomy is the ethical principle that upholds an individual's right to make decisions about their healthcare, including the choice to refuse treatment or surgery. In this scenario, the client's decision not to have surgery despite the recommendation is an exercise of autonomy. Choice A, fidelity, refers to being faithful and keeping promises, which is not applicable in this situation. Choice C, justice, pertains to fair and equal distribution of resources and treatment, not the individual's right to make decisions. Choice D, nonmaleficence, relates to the obligation to do no harm, which is not directly applicable to the client's decision to refuse surgery.