Nokea
The nurse formulates a nursing diagnosis of Spiritual distress related to advanced cancer disease. An appropriate goal for the client would be to:
- A. Start attending church or chapel services once a week.
- B. Call a chaplain and set up an appointment for spiritual guidance.
- C. Reflect on past accomplishments.
- D. Participate in spiritual activities of the client's choice.
Correct Answer: D
Rationale: Participating in spiritual activities of the client's choice respects their individual beliefs and supports resolution of spiritual distress.
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The following scenario applies to the next 1 items
The nurse in the intensive care unit (ICU) has completed an assessment on a client
Item 1 of 1
Nurses' Notes Orders
1923: Assessment completed. Peripheral vascular access device (PAD) was assessed. Erythema
and swelling were noted at the insertion site. The client reported "severe" pain, and
tenderness was endorsed when it was palpated. The infusion was stopped.
The nurse reviews the assessment and is preparing to take action. For each potential action, click to specify whether the potential action is indicated or not indicated for the client.
- A. Remove the peripheral vascular access device
- B. Obtain an order for phentolamine
- C. Notify the physician
- D. Flush the intravenous vascular access device with 5 mL of 0.9% saline (sodium chloride)
- E. Disconnect administration set
Correct Answer: A,C,F
Rationale: Removing the PVAD, notifying the physician, and disconnecting the administration set are indicated for infiltration; flushing is not indicated, and phentolamine is for extravasation.
The nurse is caring for a client following a cataract removal from their left eye. Which statement by the client's wife indicates an understanding of the post-operative care instructions?
- A. He should sleep on his left side.'
- B. He should sleep on his right side.'
- C. I will need to give him postoperative antibiotic eye drops every hour.'
- D. He needs to sleep sitting completely upright.'
Correct Answer: B
Rationale: Sleeping on the unaffected (right) side prevents pressure on the operated left eye. Sleeping on the left side risks complications, hourly eye drops are excessive, and sleeping upright is not typically required.
After a client who has had a laparoscopic cholecystectomy receives discharge instructions, which of the following client statements would indicate that the teaching has been successful? Select all that apply.
- A. I can resume my normal diet when I want.
- B. I need to avoid driving for about 4 weeks.
- C. I may experience some pain in my right shoulder.
- D. I should spend 2 to 3 days in bed before resuming activity.
- E. I can wash the puncture site with mild soap and water.
Correct Answer: C,E
Rationale: Right shoulder pain (C) can occur due to referred pain from diaphragmatic irritation. Washing the puncture site with mild soap and water (E) is correct for hygiene. Resuming a normal diet immediately (A) is incorrect; a low-fat diet is advised. Avoiding driving for 4 weeks (B) is excessive; 1-2 weeks is typical. Bed rest for 2-3 days (D) is unnecessary as early ambulation is encouraged.
After teaching the client with a femoral fracture about the purpose of treatment with skeletal traction, which of the following, if stated by the client, would indicate the need for additional teaching?
- A. To align injured bones.
- B. To provide long-term pull.
- C. To apply 25 lb of traction.
- D. To pull weight with a boot.
Correct Answer: C
Rationale: The amount of traction (e.g., 25 lb) is specific to the injury and not a general purpose, indicating a misunderstanding.
The nurse is assessing a client who has a chest tube connected to a water-seal chest tube drainage system. According to the illustrationshown, which should the nurse do?
- A. Clamp the chest tube near the insertion site to prevent air from entering the pleural cavity.
- B. Notify the physician of the amount of chest tube drainage.
- C. Add water to maintain the water seal.
- D. Lower the drainage system to maintain gravity flow.
Correct Answer: D
Rationale: To promote chest tube drainage the drainage system must be lower than the client's lungs. The amount of drainage is not abnormal; it is not necessary to notify the physician. The nurse should chart the amount and color of drainage every 4 to 8 hours.