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The nurse is talking with the spouse of a client who is eligible for hospice care. The spouse states, 'I do not know if I can make this decision. What would you do?' Which of the following responses would be appropriate for the nurse to make?
- A. These decisions are challenging. Tell me about your spouse's beliefs regarding end-of-life care.
- B. You seem overwhelmed. I will ask the chaplain to speak with you about available options.
- C. I find it helpful to investigate all options. I will get you a pamphlet about hospice services.
- D. I had to make a similar decision when my spouse was ill. Do what feels best for you.
Correct Answer: A
Rationale: The nurse should remain neutral and facilitate discussion about the client's values and preferences, helping the spouse make an informed decision without personal bias or directing to other resources prematurely.
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The nurse prepares to administer morning medications to assigned clients. Which prescription should the nurse clarify with the health care provider?
- A. Clopidogrel for client with history of stroke and platelet count of 154,000/mm² (154 x 10â¹/L)
- B. Losartan for client with hypertension who is 8 weeks pregnant
- C. Prednisone for client with herpes simplex lesions and Bell palsy
- D. Tiotropium for client with pneumonia and chronic obstructive pulmonary disease
Correct Answer: B
Rationale: Losartan is contraindicated in pregnancy due to fetal harm risks. Clopidogrel is safe with normal platelet counts, prednisone is appropriate for Bell palsy, and tiotropium is suitable for COPD despite pneumonia.
Following change-of-shift report on an orthopedic unit, which client should the nurse see first?
- A. 16 year-old who had an open reduction of a fractured wrist 10 hours ago
- B. 20 year-old in skeletal traction for 2 weeks since a motor cycle accident
- C. 72 year-old recovering from surgery after a hip replacement 2 hours ago
- D. 75 year-old who is in skin traction prior to planned hip pinning surgery.
Correct Answer: C
Rationale: Look for the client who has the most imminent risks and acute vulnerability. The client who returned from surgery 2 hours ago is at risk for life threatening hemorrhage and should be seen first.
A client calls the nurse with a complaint of sudden deep throbbing leg pain. What is the appropriate first action by the nurse?
- A. Suggest isometric exercises
- B. Maintain the client on bed rest
- C. Ambulate for several minutes
- D. Apply ice to the extremity
Correct Answer: B
Rationale: Maintain the client on bed rest. The finding suggests deep vein thrombosis. The client must be maintained on bed rest and the provider notified immediately.
A staff nurse complains to the nurse manager that an unlicensed assistive personnel (UAP) consistently leaves the work area untidy and does not restock supplies. The best initial response by the nurse manager is which of these statements?
- A. I will arrange for a conference with you and the UAP within the next week
- B. I can assure you that I will look into the matter
- C. I would like for you to approach the UAP about the problem the next time it occurs
- D. I will add this concern to the agenda for the next unit meeting
Correct Answer: C
Rationale: Helping staff manage conflict is part of the manager's role. It is appropriate to urge the nurse to confront the other staff member to work out problems without a manager's intervention when possible.
Prior to discharge from the postanesthesia care unit following a vein stripping of the left leg, the nurse should tell the client to:
- A. apply heat to the affected leg for 10 minutes out of every hour for the next 24 hours.
- B. sit with the legs up or walk but avoid prolonged standing and sitting with the feet down.
- C. avoid weight bearing on the affected leg for the next week.
- D. remove the compression bandages after 24 hours.
Correct Answer: B
Rationale: Elevating legs or walking promotes venous return, while avoiding prolonged standing/sitting prevents stasis post-vein stripping. Heat, non-weight bearing, and early bandage removal are not recommended.