A client's wife has just learned that her husband is terminally ill. She 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.

Encourage the wife to share her feelings.

Offer reassurance that she is not alone.

Remind her that her husband may still live a long time.

Answer and Explanation

The Correct Answer is B

Choice A Reason: This is incorrect because explaining that alternative treatment options may be helpful can be insensitive and unrealistic, as it may raise false hopes or imply that the husband's condition is not serious.

Choice B Reason: This is correct because encouraging the wife to share her feelings can help her cope with her grief and express her emotions in a supportive environment. The nurse should use active listening and empathic responses.

Choice C Reason: This is incorrect because offering reassurance that she is not alone can be dismissive and invalidating, as it may minimize her feelings or imply that she should not feel lonely.

Choice D Reason: This is incorrect because reminding her that her husband may still live a long time can be dishonest and inappropriate, as it may contradict the medical prognosis or imply that she should not prepare for his death.

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Correct Answer is D

Explanation

Choice A: Massage the injection site to increase absorption is not a correct instruction because it may cause bruising and bleeding. Low-molecular-weight heparin is absorbed quickly without massaging.

Choice B: Rotate injections between the abdomen and gluteal areas is not a correct instruction because it may increase the risk of hematoma and infection. The abdomen is preferred over other sites for low-molecular-weight heparin injections.

Choice C: Expel the air in the prefilled syringe prior to injection is not a correct instruction because it may result in loss of medication and inaccurate dosing. The air bubble in the prefilled syringe should be left intact.

Choice D: Inject in abdominal area at least 2 inches from the umbilicus is a correct instruction because it ensures adequate subcutaneous tissue and avoids major blood vessels and organs.

A. Decrease the flow rate to 1 L/minute. B. Place padding around the cannula tubing. C. Apply lubricant to the cannula tubing. D. Discontinue the use of the nasal cannula.

Correct Answer is B

Explanation

Choice A Reason: This is incorrect because decreasing the flow rate to 1 L/minute can compromise the client's oxygenation and worsen hypoxia. The client's oxygen saturation level is below the normal range of 95% to 100%.

Choice B Reason: This is correct because placing padding around the cannula tubing can prevent pressure ulcers and skin breakdown caused by friction and irritation from the tubing.

Choice C Reason: This is incorrect because applying lubricant to the cannula tubing can increase the risk of infection and inflammation of the nasal mucosa. Lubricant should be applied sparingly to the nares only if needed.

Choice D Reason: This is incorrect because discontinuing the use of the nasal cannula can endanger the client's life and cause respiratory failure. The client needs supplemental oxygen to maintain adequate oxygenation.

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A client's wife has just learned that her husband is terminally ill. She 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching a client how to self-administer low-molecular-weight heparin subcutaneously. Which instruction should the nurse include?

Correct Answer is D

Explanation

The nurse observes that there are reddened areas on the cheekbones of a client receiving oxygen per nasal cannula at 3 L/minute, and the client's oxygen saturation level is 92%. Which intervention would the nurse implement?

Correct Answer is B

Explanation

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A client's wife has just learned that her husband is terminally ill. She 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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