Nokea
What is the primary goal of palliative care?
- A. To cure the client's illness.
- B. To prolong the client's life.
- C. To provide comfort and improve the quality of life.
- D. To prepare the client for surgery.
Correct Answer: C
Rationale: The primary goal of palliative care is to provide comfort and improve the quality of life for clients with serious illnesses. Palliative care aims to address physical, emotional, and spiritual needs to enhance overall well-being rather than focusing on curing the underlying illness, prolonging life, or preparing for surgery. It emphasizes symptom management, pain relief, and support for patients and their families to ensure a better quality of life during the course of their illness.
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When caring for a client with a prescription for wound irrigation, which action should the nurse take?
- A. Use a 10-mL syringe with an 18-gauge needle.
- B. Cleanse the wound from the center outward.
- C. Apply a wet-to-dry dressing.
- D. Pack the wound tightly with gauze.
Correct Answer: B
Rationale: When caring for a client with a prescription for wound irrigation, the nurse should cleanse the wound from the center outward. This technique helps prevent the introduction of microorganisms into the wound, reducing the risk of contamination and promoting effective wound healing. By using a circular motion from the cleanest area to the least clean areas, debris and bacteria are moved away from the wound site, decreasing the chances of infection.
When providing teaching to a client with a new prescription for digoxin, which of the following instructions should the nurse include?
- A. Take your pulse before taking the medication.
- B. Take the medication with an antacid.
- C. Double the dose if you miss one.
- D. Take the medication with a high-fiber meal.
Correct Answer: A
Rationale: The correct instruction for a client with a new prescription for digoxin is to take their pulse before taking the medication. Digoxin can lead to bradycardia as a side effect, and monitoring the pulse helps in assessing the heart rate prior to medication administration. This precaution allows for the identification of any significant changes in heart rate that may require medical attention.
When planning care for a client with a pressure ulcer, which intervention should the nurse include in the plan?
- A. Massage the reddened area.
- B. Apply a donut-shaped cushion.
- C. Reposition the client every 3 hours.
- D. Use a transparent film dressing.
Correct Answer: D
Rationale: The correct intervention for a client with a pressure ulcer is to use a transparent film dressing. This dressing provides a protective barrier against external contaminants while allowing for wound inspection, promoting healing. Massaging the reddened area can cause further damage to the skin and should be avoided. Donut-shaped cushions can increase pressure on the ulcer site rather than alleviate it. Repositioning the client every 2 hours is a preventive measure for pressure ulcers, but once an ulcer has developed, using a transparent film dressing is a more appropriate intervention to facilitate healing and protect the wound site.
What action should the nurse take to prevent aspiration in a client receiving enteral nutrition?
- A. Flush the feeding tube with water before and after feedings.
- B. Elevate the head of the bed to 30-45 degrees during feedings.
- C. Administer the feeding slowly.
- D. Check the client's weight daily.
Correct Answer: B
Rationale: Elevating the head of the bed to 30-45 degrees during feedings is essential to prevent aspiration in clients receiving enteral nutrition. This positioning helps decrease the risk of regurgitation and aspiration by supporting proper digestion and aiding food passage through the gastrointestinal tract. Elevating the head of the bed is a standard precautionary measure recommended to reduce the chances of aspiration and should be consistently implemented during feedings to ensure client safety and optimal enteral nutrition delivery.
When teaching a client about the proper use of a cane, which of the following instructions should be included?
- A. Hold the cane on the weaker side.
- B. Move the cane forward first.
- C. Keep the cane 12 inches away from the body.
- D. Use the cane for support only when climbing stairs.
Correct Answer: B
Rationale: When using a cane, it is crucial to move the cane forward first to provide support and enhance balance. Advancing the cane before the weaker or stronger leg helps widen the base of support, thereby improving stability during ambulation. Keeping the cane too far or too close to the body can affect its supportive function. Moreover, utilizing the cane solely for stair climbing limits its overall utility in maintaining balance and stability during regular walking.