Nokea
A nurse is teaching a client about advanced directives. Which of the following statements by the client indicate an understanding of the teaching?
- A. A living will is a document that includes my wishes about health care decisions.
- B. My provider will make my health care decisions if I complete advanced directives.
- C. Advanced directives outline who inherits my material possessions in the event of my death.
- D. My partner needs to be present as a witness when I sign my living will
Correct Answer: A
Rationale: The correct answer is A: A living will is a document that includes my wishes about health care decisions. This statement demonstrates an understanding of advanced directives as a living will specifically pertains to healthcare decisions. It shows that the client comprehends that a living will outlines their preferences for medical treatment in case they are unable to communicate.
Choice B is incorrect because advanced directives are about the client's own wishes, not the provider making decisions. Choice C is incorrect as advanced directives do not pertain to material possessions but rather to healthcare decisions. Choice D is incorrect because a witness is typically required for legal purposes when signing a living will, but the presence of a partner is not mandatory.
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The nurse should notify the provider for which of the following findings?
- A. Baseline fetal heart rate 115/min
- B. Three uterine contractions within 10 minutes
- C. Prolonged decelerations
- D. Moderate variability in the fetal heart rate
Correct Answer: C
Rationale: The correct answer is C: Prolonged decelerations. This finding indicates potential fetal distress, requiring immediate provider notification to assess and intervene. Baseline fetal heart rate (A) within normal range is reassuring. Three uterine contractions (B) could be normal. Moderate variability (D) is a positive sign of fetal well-being. The focus should be on abnormal findings like prolonged decelerations (C) that may indicate compromised fetal oxygenation.
Which of the following infection control precautions should the nurse take?
- A. Remove the protective gown while in the client's room.
- B. Place the client in a private room with contact precautions.
- C. Perform hand hygiene using an alcohol-based sanitizer.
- D. Wear an N95 mask when entering the client's room.
Correct Answer: B
Rationale: The correct answer is B: Place the client in a private room with contact precautions. This is the most appropriate infection control measure for preventing the spread of infections. Placing the client in a private room helps to prevent transmission to other individuals. Contact precautions involve using gloves and gowns when in contact with the client or their environment, further reducing the risk of transmission. Choices A, C, and D are incorrect. Removing the protective gown while in the client's room (A) increases the risk of contamination. Hand hygiene using an alcohol-based sanitizer (C) is important but alone is not sufficient for contact precautions. Wearing an N95 mask when entering the client's room (D) is not necessary unless the client has airborne precautions.
The nurse is providing teaching about lithium to the client and client's adult child. Select the 3 statements the nurse should include.
- A. Blurred vision is an expected adverse effect pf this medication
- B. It will take at least a week before this medication reaches a therapeutic level.
- C. This medication can cause nausea and drowsiness.
- D. You will be placed on a low sodium diet while taking this medication.
- E. This medication can cause weight gain.
Correct Answer: B,C,E
Rationale: Blurred vision is not typical; lithium takes time to reach therapeutic levels, causes nausea/drowsiness, and often leads to weight gain. A low-sodium diet is contraindicated due to risk of toxicity.
A nurse is caring for a client whose child died from cancer. The client states 'it's hard to go on without him'. which of the following questions should the nurse ask the client first?
- A. What has helped you through difficult times in the past?
- B. Has anyone in your family committed suicide?
- C. Is there anyone you would like involved in your care?
- D. Are you thinking about ending your life?
Correct Answer: D
Rationale: The correct answer is D: Are you thinking about ending your life? This question is crucial as it directly addresses the client's statement about finding it hard to go on. It assesses the client's suicidal ideation and determines the level of risk for self-harm or suicide. It prioritizes the client's safety and well-being.
Choice A is incorrect because it does not directly address the immediate concern of potential suicide risk. Choice B is irrelevant and may lead to unnecessary distress for the client. Choice C is important but not as urgent as assessing for suicidal ideation.
Select the 3 priority actions that the nurse should take.
- A. Review cast care instructions with the child's parents
- B. Administer Ibuprofen 200 mg PO
- C. Place a nonadherent dressing on the right knee abrasion.
- D. Explain the cast application procedure to the child.
- E. Apply ice packs to the fingers and along the right forearm.
- F. Elevate the affected forearm with pillows.
Correct Answer: B,C,F
Rationale: Administering pain relief, protecting the abrasion, and elevating the limb reduce swelling and promote comfort.