Nokea
The nurse is caring for a client with end-stage kidney disease. The client says, 'I have decided that I don't want any more dialysis or treatments. This is just prolonging the inevitable.' The nurse responds, 'You have every right to do so. I will notify the nephrologist of your wishes.' Which ethical principle is being demonstrated by the nurse?
- A. justice
- B. fidelity
- C. autonomy
- D. beneficence
Correct Answer: C
Rationale: Respecting the client’s decision to refuse treatment demonstrates autonomy, prioritizing their right to self-determination.
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The nurse is caring for a client who fractured her leg in a motor vehicle accident. A cast is applied. The nurse will assess which of the following? Select all that apply.
- A. pulses
- B. capillary refill
- C. skin temperature
- D. squeeze the cast every hour to check for firmness
- E. assess for pain, numbness, tingling, or inability to move the toes
Correct Answer: A, B, C, E
Rationale: Assessing pulses, capillary refill, skin temperature, and neurovascular symptoms (pain, numbness, tingling, movement) ensures circulation and nerve function are intact; squeezing the cast is inappropriate.
The nurse is assessing a client with suspected pneumothorax. Which of the following findings would the nurse expect?
- A. Bilateral wheezing.
- B. Decreased breath sounds on one side.
- C. Clear, resonant percussion sounds.
- D. Slow, shallow respirations.
Correct Answer: B
Rationale: decreased breath sounds on the affected side are a hallmark of pneumothorax due to lung collapse
The nurse is evaluating nutritional outcomes for a client with anorexia nervosa. Which one of the following is the most objective favorable outcome for the client?
- A. The client eats all the food on her tray
- B. The client requests that family bring special foods
- C. The client's weight has increased
- D. The client weighs herself each morning
Correct Answer: C
Rationale: Weight gain is the most objective and measurable outcome for anorexia nervosa, indicating improved nutritional status and progress toward recovery.
The '5 A's' of smoking cessation intervention begin with which of the following?
- A. Advise all clients who smoke to stop smoking.
- B. Ask all clients about tobacco use at every visit.
- C. Assess clients' willingness to stop smoking.
- D. Assist the client to stop smoking.
Correct Answer: B
Rationale: The 5 A's begin with Ask (B), identifying tobacco use at every visit, followed by Advise, Assess, Assist, and Arrange.
A client with chest pain is scheduled for a heart catheterization. Which of the following would the nurse include in the client's care plan?
- A. Keep the client NPO for 12 hours after the procedure
- B. Inform the client that general anesthesia will be administered
- C. Assess the site for bleeding or hematoma once per shift
- D. Instruct the client that he might be asked to cough and breathe deeply during the procedure
Correct Answer: D
Rationale: During heart catheterization, the client may be asked to cough or breathe deeply to facilitate dye movement or assess respiratory response, a key part of preparation.