during the admission assessment of a terminally ill male client that he is an agnostiwhat is the best nursing action in response to this statement
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HESI Fundamentals Test Bank

1. During the admission assessment of a terminally ill male client, he states that he is agnostic. What is the best nursing action in response to this statement?

Correct answer: B

Rationale: The best nursing action in response to a terminally ill client stating their agnostic beliefs is to document the client's spiritual assessment. By documenting this information, the healthcare team can ensure that the client's beliefs are acknowledged and respected in their care plan. Providing information about the chapel's hours or inviting the client to a healing service may not align with the client's beliefs and preferences. Offering to contact a spiritual advisor of the client's choice may not be necessary if the client has clearly stated their agnostic beliefs, as they may not wish to engage in spiritual counseling.

2. A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficile infection. Which of the following information should the nurse include in the teaching?

Correct answer: D

Rationale: When caring for clients with Clostridium difficile infection, it is important to prevent the transmission of spores. Having family members wear a gown and gloves when visiting helps reduce the spread of the infection. Choices A, B, and C are incorrect because assigning the client to a room with a negative air-flow system, using alcohol-based hand sanitizer, and cleaning surfaces with a phenol solution are not specific measures targeted at preventing the transmission of Clostridium difficile spores.

3. A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching?

Correct answer: A

Rationale: The correct answer is to use the complete name of the medication magnesium sulfate. This is important to prevent confusion with morphine sulfate, which is abbreviated as MSO4. Choice B is incorrect as it is essential to maintain a space between the numerical dose and the unit of measure for clarity in medication documentation. Choice C is incorrect as the standard abbreviation for units is 'U' for international units, not for the dosage of insulin. Choice D is incorrect as the appropriate abbreviation for subcutaneous injection is 'SC,' not just 'SC.' Therefore, the nurse manager should emphasize using the full name of medications to avoid errors and ensure patient safety.

4. A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first?

Correct answer: A

Rationale: Performing hand hygiene is essential before any direct patient care procedure to prevent the spread of infection. Proper hand hygiene helps reduce the risk of introducing harmful microorganisms to the client, especially when dealing with a procedure like tracheostomy care. Identifying the client, preparing the sterile field, and donning sterile gloves are all important steps in tracheostomy care, but hand hygiene precedes them to maintain asepsis and ensure patient safety.

5. A client with an aggressive form of prostate cancer declines to discuss concerns after the provider briefly discusses treatment options and leaves the room. Which of the following statements should the nurse make?

Correct answer: A

Rationale: The nurse should offer support without pressuring the client. Stating, “I am available to talk if you should change your mind,” acknowledges the client's decision while leaving the door open for future discussions. Choice B is incorrect as it assumes the client's decision is final without offering further support. Choice C directs the client back to the provider without addressing the nurse's availability. Choice D commits to a future discussion without considering the client's current preference.

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