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.
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Which of the following imbalances should the nurse check for in a pregnant client with hypertension and cardiac dysrhythmias?
- A. Metabolic acidosis
- B. Hypomagnesemia
- C. Hypernatremia
- D. Hypercalcemia
Correct Answer: B
Rationale: Hypomagnesemia is commonly associated with pregnancy-induced hypertension and can contribute to cardiac dysrhythmias. Magnesium plays a critical role in neuromuscular function and electrolyte balance.
Which verbal and nonverbal communication techniques are effective with most American clients?
- A. Maintaining eye contact and using clear language.
- B. Using technical jargon and formal language.
- C. Avoiding physical proximity altogether.
- D. Speaking loudly and using gestures.
Correct Answer: A
Rationale: Maintaining eye contact and using clear, concise language aligns with cultural norms in America, enhancing communication effectiveness.
A male client has returned to the Unit following a left femoral popliteal bypass graft. Six hours later, the client's dorsalis pedis pulse cannot be palpated and his foot is cool and dusky. The nurse should:
- A. continue to monitor the foot.
- B. immediately notify the physician.
- C. notify the head nurse.
- D. assure the client that his foot is fine.
Correct Answer: B
Rationale: The client is losing the blood supply to his left foot. Continuing to monitor will not restore the blood supply to the foot. The physician should be notified immediately because the client is losing the blood supply to his left foot and is in danger of losing his foot and/or his leg. It is the responsibility of the nurse caring for the client to notify the physician, not the head nurse. This would be giving the client false assurances, which is unethical, demeaning, and could have legal consequences.
While caring for a patient following an uvulopalatopharyngoplasty (UPPP), the nurse monitors the patient for which complications in the immediate postoperative period?
- A. Snoring and foul-smelling breath
- B. Infection and electrolyte imbalance
- C. Loss of voice and severe sore throat
- D. Airway obstruction and hemorrhage
Correct Answer: D
Rationale: The correct answer is D. Airway obstruction and hemorrhage are critical complications to monitor after UPPP. Snoring (A) may persist initially, infection (B) is less common, and voice loss (C) is rare.
A healthcare professional is assessing a client who has a fracture of the femur. Vital signs are obtained on admission and again in 2 hours. Which of the following changes in assessment should indicate to the healthcare professional that the client could be developing a serious complication?
- A. Increased respiratory rate from 18 to 44/min
- B. Increased oral temperature from 36.6° C (97.8° F) to 37° C (98.6° F)
- C. Increased blood pressure from 112/68 to 120/72 mm Hg
- D. Increased heart rate from 68 to 72/min
Correct Answer: A
Rationale: Step 1: Increased respiratory rate from 18 to 44/min indicates potential respiratory distress, a serious complication post-fracture.
Step 2: Rapid breathing can signify hypoxemia, pulmonary embolism, or infection, requiring immediate intervention.
Step 3: Increased oral temperature and blood pressure within normal range are not as critical as respiratory distress.
Step 4: A slight increase in heart rate is common after a fracture and not indicative of a serious complication.