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 C

Explanation

Restarting the IV line first ensures that the client has immediate access to intravenous fluids and medications, which is critical for maintaining hydration and treatment continuity. This is especially important if the client is receiving antibiotics or other medications that need to be administered continuously or urgently.

Following the IV line, performing tracheostomy care ensures that the airway is maintained and free from obstructions. This is essential, especially in clients with compromised respiratory function. By addressing the airway next, the nurse ensures that the client can breathe effectively and is stable.

Changing the coccyx dressing is important for wound management, especially with an infected wound. Performing this last minimizes the risk of contaminating the sterile field or the dressing while the nurse is managing other tasks. This also reduces the number of times the nurse enters and exits the room, adhering to contact isolation protocols.

A. Explain the purpose of a low bacteria diet. B. Send wound drainage for culture and sensitivity. C. Monitor the client's white blood cell count. D. Use standard precautions and wear a mask. E. Institute contact precautions for staff and visitors.

Correct Answer is ["B","C","D","E"]

Explanation

Send wound drainage for culture and sensitivity.

Culturing the wound drainage helps identify the specific bacteria causing the infection and determine its antibiotic susceptibility, guiding appropriate treatment.

C. Monitor the client's white blood cell count.

Monitoring the white blood cell count helps assess for signs of infection and the body's immune response to the MRSA infection.

D. Use standard precautions and wear a mask.

Standard precautions should always be followed to prevent the transmission of infections in healthcare settings. Wearing a mask may be indicated if there is a risk of respiratory droplet transmission during wound care or other procedures.

E. Institute contact precautions for staff and visitors.

Contact precautions should be implemented to prevent the spread of MRSA to others. This includes wearing gloves and gowns when providing care, as well as educating staff and visitors about proper hand hygiene and infection control measures.

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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

A client is in contact isolation due to a stage IV coccyx wound infected with methicillin resistant Staphylococcus aureus (MRSA). The nurse plans interventions to prevent multiple re-entries to the client's room. In which order should the nurse perform the interventions?

Correct Answer is C

Explanation

A client who is paraplegic is admitted with a foul-smelling drainage from a sacral ulcer. The client is suspected to have a methicillin- resistant Staphylococcus aureus (MRSA) infection. Which nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

Correct Answer is ["B","C","D","E"]

Explanation

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