Nokea
The hospice nurse is providing end-of-life care to a client who is experiencing anorexia and cachexia. Which interventions are appropriate? Select all that apply.
- A. Allow the client to refuse food if not feeling hungry
- B. Ask if the client is experiencing any pain or nausea
- C. Involve the client in meal planning and food selection
- D. Plan for loved ones to share mealtimes with the client
- E. Provide oral care before and after meals to alleviate dry mouth
Correct Answer: A,B,D,E
Rationale: Allowing food refusal (A) respects autonomy, assessing pain/nausea (B) addresses barriers to eating, shared mealtimes (D) provide comfort, and oral care (E) improves appetite. Meal planning (C) may overwhelm a cachectic client.
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The nurse is preparing a client for a magnetic resonance cholangiopancreatography. Which statements by the client would require the nurse to obtain further assessment data? Select all that apply.
- A. I ate lunch about 4 or 5 hours ago.
- B. I got a rash the last time I had IV contrast.
- C. I had my last period 6 weeks ago.
- D. I have a hearing aid implanted in my ear.
- E. I smoked a cigarette about an hour ago.
Correct Answer: B,C,D
Rationale: A contrast allergy rash (B) requires premedication or alternative imaging. A possible pregnancy (C) needs confirmation due to MRI risks. A hearing aid implant (D) may be MRI-incompatible. Recent eating (A) is less critical unless sedation is planned, and smoking (E) is irrelevant.
A client with poorly controlled diabetes mellitus gives birth to a newborn at term gestation. When caring for the 2 hour-old newborn, which clinical finding requires the nurse to intervene?
- A. Cyanosis of hands and feet
- B. Heart rate of 165/min while crying
- C. Jitteriness
- D. Respirations of 60/min
Correct Answer: C
Rationale: Jitteriness (C) in a newborn of a diabetic mother suggests hypoglycemia, a common complication due to maternal hyperglycemia causing fetal hyperinsulinism. Immediate intervention (e.g., glucose testing) is needed. Acrocyanosis (A) is normal, heart rate 165/min while crying (B) is within range, and respirations of 60/min (D) are normal for a newborn.
A student nurse performs morning rounds and obtains a urine specimen from a client with methicillin-resistant Staphylococcus aureus who is in contact precautions. The nurse preceptor intervenes when the student performs which action?
- A. Cleans the stethoscope with 2% chlorhexidine solution before removing it from the room
- B. Removes the urine specimen cup from the room in a sealed, leak-proof bag
- C. Scrubs the Foley catheter collection port with alcohol for 15 seconds before withdrawing a urine specimen
- D. Uses an alcohol-based hand antiseptic after removing gloves
Correct Answer: A
Rationale: Chlorhexidine (A) is not standard for stethoscope cleaning in contact precautions; alcohol or approved disinfectants are used to prevent MRSA transmission. Sealed bags for specimens (B), scrubbing the port (C), and hand hygiene (D) are correct actions to maintain infection control.
The nurse is talking with a client with stable angina who has a prescription for sublingual nitroglycerin. Which of the following statements by the client would require follow-up?
- A. I shall sit down if possible before taking this medication to prevent dizziness.
- B. I may experience flushing or a headache when taking this medication.
- C. I will avoid taking the medication with grapefruit juice.
Correct Answer: C
Rationale: Nitroglycerin is not contraindicated with grapefruit juice (C), indicating a misunderstanding. Sitting down (A) prevents falls from hypotension, and flushing/headache (B) are expected side effects, both correct.
The nurse is caring for a client with suspected colorectal cancer. Which of the following findings would support a diagnosis of colorectal cancer? Select all that apply.
- A. Fatigue
- B. Blood in the stool
- C. Change in bowel habits
- D. Unintentional weight loss
- E. Elevated hemoglobin level
Correct Answer: A,B,C,D
Rationale: Colorectal cancer often presents with fatigue (A) due to anemia or systemic effects, blood in the stool (B) from tumor bleeding, changes in bowel habits (C) like diarrhea or constipation, and unintentional weight loss (D) from malignancy-related cachexia. Elevated hemoglobin (E) is unlikely, as anemia is more common due to chronic blood loss.