A home health nurse is conducting an initial home visit for a client who has terminal breast cancer. The client has two school-age children and a limited support system. Which of the following is the priority nursing action?
Inform the client of available community resources.
Assist the client in finding child care options.
Agree upon short-term goals for the client.
Ask the client about their understanding of the diagnosis.
The Correct Answer is D
A. Inform the client of available community resources is an important action because the client will likely need additional support, such as hospice care, counseling, or child care services. However, before providing resources, the nurse must assess the client’s understanding of their diagnosis to ensure any interventions are tailored to their current needs and readiness.
B. Assist the client in finding child care options - While important, addressing community resources takes precedence as it may encompass finding child care options as well.
C. Agree upon short-term goals for the client - Establishing goals is important but may come after addressing immediate needs.
D. Ask the client about their understanding of the diagnosis is the priority action. Before any other interventions, the nurse must assess the client’s knowledge and perception of their condition. This foundational step allows the nurse to provide appropriate education, clarify any misconceptions, and ensure that all care planning aligns with the client’s needs, values, and readiness to engage in discussions about their care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The water seal chamber should contain at least 2 cm of water to maintain the seal and prevent air from entering the pleural space. Only 1 cm of water is inadequate and requires intervention.
B. Tidaling, or fluctuation of water with respirations, is an expected finding and indicates that the system is functioning properly.
C. A suction chamber pressure of -20 cm H₂O is the standard setting for chest tube drainage systems and does not require intervention.
D. A drainage collection chamber that is one-third full is within normal limits and simply indicates the need to continue monitoring output.
Correct Answer is B
Explanation
A. A gastric residual volume of 250 mL following 2 hours of infusion may indicate potential intolerance to the feeding, but it is not necessarily an immediate emergency unless it exceeds the facility’s threshold for residuals.
B. The client lying in a supine position poses a significant risk for aspiration, especially following a laryngectomy, where airway protection is compromised. Immediate intervention is necessary to reposition the client and reduce the risk of aspiration pneumonia.
C. While the infusion pump being off is concerning, it may not require immediate intervention as long as the nurse is aware and can address it promptly.
D. Not dating the enteral feeding bag and tubing is important for infection control; however, it does not require immediate intervention compared to the risk posed by a supine position.
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