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The male client diagnosed with metastatic cancer of the bladder is emaciated and refuses to eat. Which nursing action is an example of the ethical principle of paternalism?
- A. The nurse allows the client to talk about not wanting to eat.
- B. The nurse tells the client if he does not eat, a feeding tube will be placed.
- C. The nurse consults the dietitian about the client’s nutritional needs.
- D. The nurse asks the family to bring favorite foods for the client to eat.
Correct Answer: B
Rationale: Paternalism involves acting in the client’s best interest without their consent. Threatening a feeding tube overrides the client’s refusal to eat. Allowing discussion, consulting a dietitian, or involving family respect autonomy.
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The client diagnosed with renal calculi is scheduled for lithotripsy. Which postprocedure nursing task is the most appropriate to delegate to the UAP?
- A. Monitor the amount, color, and consistency of urine output.
- B. Teach the client about care of the indwelling Foley catheter.
- C. Assist the client to the car when being discharged home.
- D. Take the client’s postprocedural vital signs.
Correct Answer: C
Rationale: Assisting the client to the car is a non-clinical task within the UAP’s scope. Monitoring urine, teaching catheter care, and taking vital signs require nursing judgment and are not delegable.
Which nursing action is most appropriate when the client complains about being thirsty because of the fluid restrictions?
- A. Giving the client hard candy to suck
- B. Providing the client with ice chips
- C. Offering the client an ice cream bar
- D. Supplying the client with fresh fruit
Correct Answer: A
Rationale: Hard candy stimulates saliva production, alleviating thirst without contributing to fluid intake, which is restricted.
Which response by the nurse is most appropriate?
- A. His bladder retraining is coming along, and before long he will be urinating like normal.
- B. He seems to have more incontinence in the afternoon and evening.
- C. In order to protect his privacy, I can't give you that information.
- D. Bladder retraining is slow work. We have to take him to the toilet every 2 hours.
Correct Answer: C
Rationale: To comply with HIPAA, the nurse must protect the client's privacy and not disclose health information without consent, making this the most appropriate response.
When a client asks the clinic nurse why women have more bladder infections than men, which answer is most accurate?
- A. The male urethra is straighter, which facilitates elimination of pathogens.
- B. The male urethra is lined with a layer of mucous membrane, which traps microorganisms.
- C. The female urethra is shorter, and pathogens enter the bladder more easily.
- D. The female urethra has a larger diameter and is more easily contaminated.
Correct Answer: C
Rationale: The shorter female urethra allows pathogens easier access to the bladder, increasing the risk of bladder infections.
The male client diagnosed with CKD has received the initial dose of erythropoietin, a biologic response modifier, one (1) week ago. Which complaint by the client indicates the need to notify the health-care provider?
- A. The client complains of flu-like symptoms.
- B. The client complains of being tired all the time.
- C. The client reports an elevation in his blood pressure.
- D. The client reports discomfort in his legs and back.
Correct Answer: C
Rationale: Erythropoietin can cause hypertension as a side effect, which is significant in CKD patients and warrants notifying the provider. Flu-like symptoms and fatigue are common and expected, while leg/back discomfort is less specific.