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The nurse is caring for a client who is terminally ill. Upon admission, the client signed advance directives indicating that she does not wish to have any resuscitative measures. The client is now in and out of consciousness. Her daughter comes to the nurse and says, 'I want everything done for my mother if she stops breathing.' How should the nurse respond?
- A. Remove the 'Do Not Resuscitate' order from the chart.
- B. Discuss the client's advance directives with the daughter.
- C. Have the daughter sign a consent form since her mother is in and out of consciousness.
- D. When the client is conscious, ask her again what her wishes are.
Correct Answer: B
Rationale: Discussing advance directives respects the client's documented wishes, clarifying the DNR order with the daughter to ensure alignment.
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The nurse is caring for a child with celiac disease. The nurse's discharge teaching plan should include:
- A. Dietary instructions and a list of foods to be avoided
- B. Hand-washing instructions to prevent disease transmission
- C. Instructions to continue antibiotics for 1 week
- D. Explaining that one attack confers immunity
Correct Answer: A
Rationale: Celiac disease requires a gluten-free diet, so dietary instructions and a list of foods to avoid are essential, making A correct. Hand-washing , antibiotics , and immunity are not relevant to celiac disease management.
A woman is in the clinic complaining of urinary frequency, urgency, and pain on urination. Orders include a urine for culture and administration of sulfisoxazole (Gantrisin) and phenazopyridine (Pyridium.) Which action should the nurse take first?
- A. Obtain a clean catch urine from the client.
- B. Ask the client if she is allergic to sulfa drugs.
- C. Administer the sulfisoxazole (Gantrisin).
- D. Administer the phenazopyridine (Pyridium).
Correct Answer: B
Rationale: Checking for sulfa allergies is critical before administering sulfisoxazole, as allergies can cause severe reactions, prioritizing safety.
The nurse is caring for clients on a psychiatric unit and is suddenly faced with multiple issues.
Which of the following situations require the nurse's IMMEDIATE attention?
- A. A client with bipolar disorder walks into the dayroom in her underwear and begins dancing.
- B. A client with depression says to the nurse, 'My plan is complete, and I'm ready to go for it.'
- C. A client recovering from substance abuse says to the nurse, 'My plan is complete, and I'm ready to go for it.'
- D. A client with schizophrenia tells the nurse that it's 'God's will' that he destroy the 'evil TV'.
Correct Answer: B
Rationale: Strategy: 'Require IMMEDIATE intervention' indicates that you are looking for the least stable situation. (1) should remove to quiet area, decrease environmental stimuli (2) correct-could indicate impending suicide, requires immediate follow-up (3) potential suicide is more immediate concern (4) command hallucination, potential suicide takes priority
A symptom of impending cardiac decompensation in a pregnant client with heart disease is:
- A. Increasing dyspnea
- B. Transient palpitations
- C. Occasional activity intolerance
- D. Periodic shortness of breath
Correct Answer: A
Rationale: Increasing dyspnea signals worsening cardiac function and potential decompensation, a critical symptom in pregnant clients with heart disease. Other symptoms are less specific.
Which laboratory test conducted on the client with diabetes mellitus indicates compliance?
- A. Fasting blood glucose
- B. Two-hour post-prandial
- C. Hgb A-1C
- D. Dextrostix
Correct Answer: C
Rationale: Hgb A-1C reflects average blood glucose over 2-3 months, indicating long-term compliance. Options A, B, and D provide short-term snapshots and are less reliable for compliance.