Nokea
The nurse caring for a terminally ill client asks if the client has an advance directive. The client states, 'I already have a power of attorney.' What is the best response by the nurse?
- A. A power of attorney (POA) is good to have in place. It sounds like you are on the right track.
- B. Great. Your POA can start to make decisions for you when you are no longer able to do so.
- C. Many people find a lawyer at this stage of life. A lawyer can help you get your affairs in order.
- D. There are many types of POAs. Let's clarify if your POA can make health care decisions for you.
Correct Answer: D
Rationale: Clarifying if the POA includes healthcare decisions (D) ensures proper advance directive planning. Vague affirmations (A, B) or suggesting a lawyer (C) do not address the need for a healthcare-specific POA.
You may also like to solve these questions
The nurse receives the handoff of care report on four clients. Which client should the nurse see first?
- A. Client reporting incisional pain of 8 on a scale of 0-10 with a respiratory rate of 25/min who had a right pneumonectomy 12 hours ago
- B. Client with a left pleural effusion who has crackles, absent breath sounds in the left base, and an SpO2 of 94% on room air
- C. Client with a temperature of 100.4 F (38 C) and a respiratory rate of 12/min who had a small bowel resection 1 day ago
- D. Client with pneumonia who has a temperature of 97.6 F (36.4 C), has an SpO2 of 93% on 4 L/min supplemental oxygen, and is becoming restless
Correct Answer: D
Rationale: Restlessness in a pneumonia client with low SpO2 (D) suggests worsening hypoxia, requiring immediate assessment. Severe pain (A) is urgent but stable. Pleural effusion (B) and fever (C) are less critical.
A client with emphysema visits the clinic. While teaching about proper nutrition, the nurse should emphasize that the client should
- A. Eat foods high in sodium to increase sputum liquefaction
- B. Use oxygen during meals to improve gas exchange
- C. Perform exercise after respiratory therapy to enhance appetite
- D. Cleanse the mouth of dried secretions to reduce risk of infection
Correct Answer: B
Rationale: Use oxygen during meals to improve gas exchange. This supports breathing and energy needs during eating.
The nurse in the mental health unit is talking with several clients during group therapy. A client becomes angry and throws a fire extinguisher at another client. Which of the following actions would be a priority for the nurse to take?
- A. Activate the rapid response team.
- B. Approach the client calmly and acknowledge the client's feelings.
- C. Escort other clients away from the area.
- D. Inform the client that the action was dangerous and unacceptable.
Correct Answer: C
Rationale: Ensuring safety by escorting others away (C) is the priority. Rapid response (A) may be premature, approaching the client (B) risks escalation, and informing of consequences (D) is secondary.
The physician has ordered dressings with sulfamylon cream for a client with full thickness burns of his hands and arms. Before dressing changes, the nurse should give priority to:
- A. Administering pain medication
- B. Checking the adequacy of urinary output
- C. Requesting a daily complete blood count
- D. Obtaining a blood glucose by finger stick
Correct Answer: A
Rationale: Sulfamylon dressing changes are painful, so administering pain medication is the priority. Urinary output , blood count , and glucose are important but secondary.
A nurse is providing a parenting class to individuals living in a community of older homes. In discussing formula preparation, which of the following is most important to prevent lead poisoning?
- A. Use ready-to-feed commercial infant formula
- B. Boil the tap water for 10 minutes prior to preparing the formula
- C. Let tap water run for 2 minutes before adding to concentrate
- D. Buy bottled water labeled 'lead free' to mix the formula
Correct Answer: C
Rationale: Use of lead-contaminated water to prepare formula is a major source of poisoning in infants. Letting tap water run for several minutes will diminish the lead contamination.