Nokea
Priority Decision: The husband and daughter of a Hispanic woman dying from pancreatic cancer refuse to consider using hospice care. What is the first thing the nurse should do?
- A. Assess their understanding of what hospice care services are.
- B. Ask them how they will care for the patient without hospice care.
- C. Talk directly to the patient and family to see if she can change their minds.
- D. Accept their decision since they are Hispanic and prefer to care for their own.
Correct Answer: A
Rationale: The nurse should assess their understanding of hospice care services to ensure they are making an informed decision based on accurate information rather than assumptions or cultural biases.
You may also like to solve these questions
The nurse is caring for a client with cirrhosis of the liver with ascites. When instructing nursing assistants in the care of the client, the nurse should emphasize that:
- A. The client should remain on bed rest in a semi-Fowler's position.
- B. The client should alternate ambulation with bed rest with legs elevated.
- C. The client may ambulate and sit in chair as tolerated.
- D. The client may ambulate as tolerated and remain in semi-Fowlers positioning bed.
Correct Answer: D
Rationale: Semi-Fowler's position aids in breathing and reduces pressure on the abdomen.
While caring for an unconscious patient, the nurse discovers a stage 2 pressure ulcer on the patient’s heel. During care of the ulcer, what is the nurse’s understanding of the patient’s perception of pain?
- A. The patient will have a behavioral response if pain is perceived.
- B. The area should be treated as a painful lesion, using gentle cleansing and dressing.
- C. The area can be thoroughly scrubbed because the patient is not able to perceive pain.
- D. All nociceptive stimuli that are transmitted to the brain result in the perception of pain.
Correct Answer: B
Rationale: The correct answer is B. Even in unconscious patients, the area should be treated gently to avoid exacerbating potential pain.
What type of shock is the client experiencing if there is no urine return after inserting a Foley catheter?
- A. Decreased blood pressure
- B. Increased heart rate
- C. Fluid retention
- D. Muscle cramps
Correct Answer: A
Rationale: Decreased blood pressure is a primary symptom in fluid imbalance as a result of inadequate circulating volume, leading to hypotension and possible shock.
A patient is scheduled for a hemorrhoidectomy at an ambulatory day-surgery center. An advantage of performing surgery at an ambulatory center is a decreased need for
- A. laboratory tests and perioperative medications.
- B. preoperative and postoperative teaching by the nurse.
- C. psychologic support to alleviate fears of pain and discomfort.
- D. preoperative nursing assessment related to possible risks and complications.
Correct Answer: A
Rationale: Ambulatory centers often streamline processes, reducing the need for extensive laboratory tests and perioperative medications.
A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?
- A. Check the tubing connections for leaks.
- B. Check the suction control outlet on the wall.
- C. Clamp the chest tube.
- D. Continue to monitor the client's respiratory status.
Correct Answer: A
Rationale: The correct answer is A: Check the tubing connections for leaks.
1. Slow, steady bubbling in the suction control chamber indicates an air leak in the system.
2. Checking the tubing connections for leaks is the appropriate action to identify and fix the issue.
3. This helps maintain the integrity of the closed chest drainage system and prevent complications.
Other choices are incorrect:
B: Checking the suction control outlet on the wall is not necessary as the issue is likely within the tubing system.
C: Clamping the chest tube could lead to tension pneumothorax and is not recommended unless ordered by a physician.
D: Continuing to monitor the client's respiratory status does not address the underlying problem of the air leak.