A client's spouse has just learned of the client's terminal illness. The spouse is sitting in the corner of the client's room crying, and says to the nurse, "I feel as if I'm already so alone." Which action should the nurse take first?

Explain that alternative treatment options may be helpful.

Remind the spouse that the client may still live a long time.

Offer reassurance that the spouse is not alone.

Encourage the spouse to share their feelings.

Answer and Explanation

The Correct Answer is C

C. The first action the nurse should take is to offer reassurance to the spouse that they are not alone. This statement acknowledges the spouse's emotional distress and provides comfort and support during a difficult time. It also validates the spouse's feelings of loneliness and acknowledges the importance of their presence and support for the client.

A and B focus on the client's illness or prognosis, which may not be the immediate concern for the spouse at this moment.

D, while valuable, may come after the initial reassurance to create a supportive environment for the spouse to share their feelings when they feel ready.

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Correct Answer is B

Explanation

B. The needle should be inserted with the bevel facing up (visible through the skin). The goal is to deposit the medication into the epidermal layer (not subcutaneous tissue).

A. Massaging the site after injection can cause the medication to spread beyond the intended area, leading to inaccurate results or potential complications.

C. The correct angle for an intradermal injection is 5 to 15-degree angle. This angle allows for proper placement of the medication just below the epidermis.

D. Intradermal injections are usually administered on the forearm or the upper back, where the skin is thin and easily lifted to create a wheal.

A. Elevate the head of the bed to a 45-degree angle. B. Remove dentures or other oral appliance. C. Lift and lock the side rails in place. D. Apply the client's positive airway pressure device.

Correct Answer is D

Explanation

D. Severe obstructive sleep apnea poses a risk of respiratory compromise, particularly when compounded by the effects of opioid analgesics, which can depress respiratory drive. Applying the client's prescribed positive airway pressure (PAP) device, such as continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP), helps maintain airway patency and ensures adequate ventilation

A. It promotes better alignment of the airway, decreasing the likelihood of obstruction by the tongue or soft tissues. While this intervention is beneficial for managing OSA, it may not be the most critical intervention in this context.

B. Removing dentures or oral appliances may be necessary to prevent airway obstruction, especially during sleep when muscle tone is decreased. However, it is not the most critical intervention in this scenario

C. Securing side rails is important for client safety, especially in postoperative settings where clients may be at risk of falls. However, it does not directly address the client's obstructive sleep apnea or potential respiratory compromise from opioid administration.

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A client's spouse has just learned of the client's terminal illness. The spouse is sitting in the corner of the client's room crying, and says to the nurse, "I feel as if I'm already so alone." Which action should the nurse take first?

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Naxlex Comprehensive Predictor Exams

The nurse is administering an intradermal (ID) injection to a client. Which action should the nurse take?

Correct Answer is B

Explanation

A nurse administers an opioid analgesic to a postoperative client who also has severe obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client alone?

Correct Answer is D

Explanation

An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep. Which action(s) should the nurse suggest to the client to help improve sleep? Select all that apply.

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It is most important for the nurse to recalculate the Braden scale score for a client who has developed which problem?

A client is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurse implement?

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