A nurse is assisting in the care of a client who has terminal cancer. Which of the following actions should the nurse take to promote the client's autonomy?
Be honest with the client about their prognosis.
Include the client's input when setting treatment goals.
Keep an agreement made with the client to administer an antiemetic medication
Administer pain medication to the client on a routine schedule.
The Correct Answer is B
A. Be honest with the client about their prognosis: Honesty is essential for building trust but does not alone promote autonomy. Autonomy specifically involves allowing the client to make informed decisions about their own care based on truthful information.
B. Include the client's input when setting treatment goals: Including the client’s input directly supports their autonomy by allowing them to actively participate in decisions about their care, treatments, and end-of-life goals, ensuring their personal values and wishes are respected.
C. Keep an agreement made with the client to administer an antiemetic medication: Honoring agreements builds trust and supports ethical practice but focuses more on fidelity than directly on promoting autonomy, which centers on the client’s decision-making role.
D. Administer pain medication to the client on a routine schedule: Providing pain management is important for comfort but does not by itself promote autonomy unless it involves client participation in deciding how and when the medication is administered.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Position the client's finger above their heart: The finger should be positioned below the level of the heart to encourage blood flow, making it easier to obtain a sufficient blood sample for testing. Elevating the finger would decrease blood flow and make collection more difficult.
B. Apply sterile gloves prior to performing the test: Clean, non-sterile gloves are sufficient for routine blood glucose monitoring. Sterile gloves are not necessary unless performing procedures that require a sterile environment, such as surgery or central line dressing changes.
C. Puncture the side of the client's finger: The sides of the fingertips have fewer nerve endings compared to the pads, making the procedure less painful. Additionally, puncturing the side helps promote better blood flow and reduces the risk of bruising and soreness.
D. Milk the finger site: Milking or squeezing the finger excessively can cause hemolysis or contamination of the blood sample with tissue fluid, leading to inaccurate glucose readings. Gentle pressure may be used if needed, but forceful milking should be avoided.
Correct Answer is ["A","C","F","G"]
Explanation
- Weight: The client has gained over 1 kg (about 2.2 lb) within a week, suggesting fluid retention. In combination with crackles, edema, and cardiomegaly, this weight gain indicates worsening heart failure and requires prompt intervention to manage fluid overload.
- Potassium: A potassium level of 3.5 mEq/L is at the lower limit of normal. While it should be monitored, it does not independently demand immediate action unless it trends lower or the client shows symptoms of hypokalemia.
- Pedal pulses: Pedal pulses have decreased from 2+ to 1+, and the extremities are now cool. These changes suggest compromised peripheral circulation, likely related to decreased cardiac output, and warrant further assessment and management.
- Temperature: The client’s temperature is within the normal range. There are no signs of fever or hypothermia, so this finding does not require immediate action based on the current clinical data.
- Orientation: The client remains alert and oriented, with no noted decline in mental status. Therefore, orientation findings are stable and do not necessitate further immediate intervention.
- Chest x-ray: The presence of cardiomegaly on chest x-ray suggests worsening heart failure or fluid overload. This finding is significant and requires timely medical evaluation and management to prevent further cardiac decompensation.
- Urine output: The client’s urine output has drastically decreased from 520 mL/hr to 160 mL in 8 hours, indicating impaired renal perfusion or acute kidney injury. This is a critical finding and requires immediate provider notification and intervention.
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