Nursing Elites

1. A client with end-stage heart failure who is awaiting a transplant appears depressed and states, 'I know a transplant is my last chance, but I don't want to become a vegetable.' How should the nurse respond?

• A. Would you like information about advance directives?
• B. I will arrange for a psychiatrist to speak with you.
• C. Do you want to come off the transplant list?
• D. Would you like to speak with a priest or chaplain?

Correct answer: A

Rationale: The client is expressing a fear of negative outcomes related to the transplant. By offering information about advance directives, the nurse allows the client to discuss concerns and preferences for end-of-life care. This response shows empathy, acknowledges the client's autonomy, and addresses the client's fears while providing support and information.

2. A client with end-stage renal disease (ESRD) is receiving hemodialysis. Which assessment finding indicates a need for immediate action?

• A. Weight gain of 1 kg since the last dialysis session
• B. Blood pressure of 150/90 mm Hg
• C. Potassium level of 6.5 mEq/L
• D. Hemoglobin level of 10 g/dL

Correct answer: C

Rationale: A potassium level of 6.5 mEq/L is critically high and can lead to life-threatening cardiac dysrhythmias, requiring immediate intervention. Hyperkalemia is a common complication in clients with ESRD due to the kidneys' inability to excrete potassium effectively. High potassium levels can result in serious cardiac consequences such as arrhythmias, cardiac arrest, and death. Prompt action is necessary to prevent these severe complications.

3. What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP) for a client receiving O2 at 4 liters per nasal cannula?

• A. Apply water-soluble ointment to nares and lips.
• B. Periodically adjust the oxygen flow rate.
• C. Remove the tubing from the client's nose.
• D. Turn the client every 2 hours or as needed.

Correct answer: A

Rationale: When a client is receiving oxygen at a high flow rate, it can cause drying of the nasal passages and lips. Therefore, a comfort measure that can be delegated to unlicensed assistive personnel (UAP) is applying water-soluble ointment to the client's nares and lips. Adjusting the oxygen flow rate should be done by licensed nursing staff, not UAP. Removing the tubing can disrupt the oxygen delivery and should be performed by trained personnel. Turning the client every 2 hours is a general comfort measure but is not specific to addressing the drying effects of oxygen therapy.

4. A client is prescribed nicotine replacement therapy. Which statement should the nurse include in this client's teaching?

• A. Smoking while taking this medication will increase your risk of a stroke.
• B. Make a list of reasons why smoking is a bad habit.
• C. Stopping this medication suddenly increases your risk for a heart attack.
• D. Rise slowly when getting out of bed in the morning.

Correct answer: A

Rationale: When a client is prescribed nicotine replacement therapy, it is crucial to emphasize that smoking while using this therapy can increase the risk of a stroke. Smoking while on nicotine replacement therapy can lead to excessive nicotine levels in the body, elevating cardiovascular risks. Therefore, the nurse should educate the client on the importance of avoiding smoking while utilizing this medication. Choices B, C, and D are not relevant to the specific teaching required for a client on nicotine replacement therapy.

5. Which action best demonstrates respect for autonomy when working with a client?

• A. Asks if the client has questions before signing a consent form
• B. Provides the client with accurate information when questioned
• C. Honors the promises made to the client and family
• D. Ensures fair treatment of the client compared to others

Correct answer: A

Rationale: Respect for autonomy involves allowing individuals to make decisions about their care. By asking if the client has questions before signing a consent form, the nurse is respecting the client's right to make informed choices and decisions regarding their healthcare. This action supports the principle of self-determination and autonomy in healthcare decision-making.

Similar Questions