A nurse is assisting with the admission of a client to hospice care. The client's partner asks the nurse why the client is becoming verbally aggressive. Which of the following responses should the nurse make?

"We can discuss this after completing the admission process."

"Your partner is experiencing an expected response to the dying process."

"Your partner is in the denial stage of grief."

"You should discuss this problem with your family members."

Answer and Explanation

The Correct Answer is B

A. "We can discuss this after completing the admission process.": This dismisses the partner’s concern and ignores a valuable opportunity for emotional support.

B. "Your partner is experiencing an expected response to the dying process.": Verbal aggression is often a manifestation of the Anger stage of grief (Kübler-Ross) or can be related to terminal restlessness/delirium. Normalizing this helps the partner understand the behavior.

C. "Your partner is in the denial stage of grief.": While they may be in a stage of grief, aggression is typically associated with Anger, not Denial.

D. "You should discuss this problem with your family members.": This avoids the nurse's responsibility to provide education and support to the family during hospice admission.

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Free Nursing Study Resources

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

Explanation

A. Elevate the client's hand above the level of the heart.: The hand should be kept dependent (below heart level) to increase blood flow to the fingertips.

B. Squeeze the client's finger until a blood drop forms.: Excessive squeezing (milking) can cause hemolysis or dilute the specimen with interstitial fluid.

C. Prick the side of the client's finger.: The sides of the finger have fewer nerve endings and better vascularity than the center of the fingertip.

D. Apply clean gloves.: Standard precautions must be followed when handling blood.

E. Cleanse the client's finger with an iodine swab.: Iodine can interfere with results (especially glucose). Alcohol is typically used and must be allowed to dry completely.

A. Notify the charge nurse of the client's condition. B. Review the client's most recent SaO2 level in the medical record. C. Check the client's medical records to see which medications were recently administered. D. Recheck the client's SaO2 level after having the client cough and clear their throat.

Correct Answer is D

Explanation

A. Notify the charge nurse of the client's condition.: While necessary, it is not the first action in an acute assessment situation.

B. Review the client's most recent SaO2 level in the medical record.: This provides context but does not address the client's current acute respiratory distress.

C. Check the client's medical records to see which medications were recently administered.: This delays immediate intervention for a potentially unstable client.

D. Recheck the client's SaO2 level after having the client cough and clear their throat.: This is a simple, immediate nursing intervention to clear the airway and ensure the reading is accurate and not affected by secretions.

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A nurse is assisting with the admission of a client to hospice care. The client's partner asks the nurse why the client is becoming verbally aggressive. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to obtain a capillary blood specimen from a client. Which of the following actions should the nurse take? (Select all that apply.)

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

Explanation

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Correct Answer is D

Explanation

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