Nokea
The nurse is caring for a client diagnosed with end-stage renal disease. What areas are appropriate to assess to determine the client's wishes for end-of-life nursing care?
- A. Preferred place for death
- B. Client expectations for nursing care
- C. Financial responsibilities for the funeral
- D. Where the funeral and burial will take place
- E. Use of and the level of life-sustaining measures
- F. Expectations regarding pain control and symptom management
Correct Answer: A,B,E,F
Rationale: The nurse must assess the client's wishes for end-of-life nursing care because these can influence how the nurse sets priorities for planning and implementing care. End-of-life assessment related to nursing care should include the preferred place for death, client expectations for nursing care, the use of and the level of life-sustaining measures, and expectations regarding pain control and symptom management. Financial responsibilities for the funeral and where the funeral and burial will take place are issues that the client may want to discuss, but they are unrelated to nursing care.
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The client diagnosed with prostatitis asks the nurse, 'Why do I need to take a stool softener? The problem is with my urine, not my bowels!' Which response should the nurse make to the client?
- A. This is a standard medication prescription for anyone with a urine problem.
- B. This will keep the bowel free of feces, which helps decrease the swelling inside.
- C. Being constipated puts you at more risk for developing complications of prostatitis.
- D. This will help you prevent constipation because straining is painful with prostatitis.
Correct Answer: D
Rationale: Stool softeners prevent constipation, which can cause painful straining in clients with prostatitis, exacerbating discomfort. They are not standard for all urinary issues, do not directly reduce swelling, and constipation does not cause complications of prostatitis.
The nurse is percussing the anterior thorax and the abdomen for tones and expects to note dullness in which anatomic location? (Refer to figure.)
- A. Location 1
- B. Location 2
- C. Location 3
- D. Location 4
Correct Answer: C
Rationale: Percussion involves tapping the body with the fingertips to set the underlying structures in motion and thus produce a sound. Dullness will be noted over the liver, located in the upper right quadrant of the abdomen and beneath the lower ribs on the right side. Tympany is the most common percussion tone heard in the abdomen and is caused by the presence of gas. Resonance is the percussion tone heard between the ribs.
The nurse reviews the pattern of a nonstress test performed on a pregnant client and interprets the finding as which result? (Refer to figure.)
- A. Reactive
- B. Abnormal
- C. Nonreactive
- D. Non-reassuring
Correct Answer: A
Rationale: A nonstress test assesses fetal well-being and evaluates the ability of the fetal heart to accelerate, often in association with fetal movement. Accelerations of the fetal heart rate are associated with adequate oxygenation, a healthy neural pathway, and the fetal heart's ability to respond to stimuli. A reactive test is described as at least two fetal heart rate accelerations, with or without fetal movement, occurring within a 20-minute period and peaking at least 15 beats/minute above the baseline and lasting 15 seconds from baseline to baseline. This recording (see figure) identifies a reactive nonstress test. The fetal heart rate acceleration peaks at least 15 beats/minute and lasts for at least 15 seconds in response to fetal movement. A nonreactive test is an abnormal or nonreassuring test. In a nonreactive test, the recording does not demonstrate the required characteristics of a reactive test within a 40-minute period.
The nurse is teaching umbilical cord care to a new mother. What information should the nurse provide to the mother related to cord care?
- A. Alcohol is the only agent to use to clean the cord.
- B. Cord care is done only at birth to control bleeding.
- C. It takes at least 21 days for the cord to dry up and fall off.
- D. The process of keeping the cord clean and dry will decrease bacterial growth.
Correct Answer: D
Rationale: The cord should be kept clean and dry to decrease bacterial growth. It should be cleansed two to three times a day with a prescribed agent. Usually the cord is cleansed with soap and water around base of the cord where it joins the skin. The primary health care provider is notified of any odor, discharge, or skin inflammation. The diaper should not cover the cord because a wet or soiled diaper will slow or prevent drying of the cord and foster infection. Cord care is required until the cord dries up and falls off between 7 and 14 days after birth.
The nurse teaches a preoperative client about the nasogastric (NG) tube that will be inserted in preparation for surgery. The nurse determines that the client understands when the tube will be removed during the postoperative period based on which statement by the client?
- A. When my doctor says so.
- B. When I can tolerate food without vomiting.
- C. When my gastrointestinal (GI) system is healed.
- D. When my bowels begin to function again and I begin to pass gas.
Correct Answer: D
Rationale: NG tubes are discontinued when normal function returns to the GI tract. Although the surgeon determines when the NG tube will be removed, 'When my doctor says so' does not determine the effectiveness of teaching. Food would not be administered unless bowel function returns. The tube will be removed well before GI healing occurs.