A nurse is caring for a client who has metastatic bone cancer. The client states, "I want to go home to die." The family is concerned about meeting the client's care needs at home. Which of the following actions should the nurse take?

Discuss initiating hospice care with the client and family.

Talk with the provider about extending the client's hospital stay.

Write a referral to place the client in a nursing home.

Inform the client's family that they are responsible for providing palliative care.

Answer and Explanation

The Correct Answer is A

A. Discussing initiating hospice care is appropriate to address the client's desire to go home for end-of-life care and to provide support and resources for the family.
B. Extending the hospital stay may not align with the client's wishes for end-of-life care at home.
C. Placing the client in a nursing home may not be in line with the client's preference to go home.
D. While the family may provide palliative care, the nurse should also explore hospice care options for comprehensive support.

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Correct Answer is B

Explanation

A. A client being discharged to a long-term care facility may need comprehensive discharge planning, which involves familiarity with long-term care requirements, but this is not typically within the primary expertise of a PACU nurse.
B. A client who is postoperative following a lobectomy and has a chest tube falls within the PACU nurse's area of expertise. PACU nurses are experienced in monitoring and managing postoperative clients, including those with chest tubes, as these clients require close monitoring for complications such as respiratory distress or chest tube malfunction.
C. Teaching about insulin self-administration is important, but this task is more suited to nurses experienced in chronic care management, such as those from medical-surgical or endocrinology units.
D. Teaching prior to initiating cardiac rehabilitation requires specialized knowledge in cardiac care, which may not be the primary focus of a PACU nurse's practice.

A. A client who had a hemi-colectomy and placement of a colostomy B. A client who has a chest tube following a fall from a ladder C. A client receiving continuous enteral feeding through NG tube D. A client who Crohn's disease and has an ileostomy

Correct Answer is C

Explanation

A. A client with a hemi-colectomy and colostomy is not at highest risk for aspiration.
B. A client with a chest tube may have respiratory issues but is not at the highest risk for aspiration.
C. A client receiving continuous enteral feeding through an NG tube is at the highest risk for aspiration due to the risk of feeding contents entering the airway.
D. A client with Crohn's disease and an ileostomy is not at the highest risk for aspiration.

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A nurse is caring for a client who has metastatic bone cancer. The client states, "I want to go home to die." The family is concerned about meeting the client's care needs at home. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the medical-surgical unit is assigning client care to a nurse who is floating from the PACU. The nurse should recognize that the float nurse is most qualified to care for which of the following clients?

Correct Answer is B

Explanation

A nurse is caring for four clients. Which of the following clients should the nurse identify as having the highest risk for aspiration?

Correct Answer is C

Explanation

A nurse is administering morphine 2 mg IV every 2 to 4 hr to a client who has an abdominal incision. The nurse should monitor the client for which of the following adverse effects?

A nurse is assessing a client who has acute cocaine toxicity. Which of the following findings should the nurse expect? (Select all that apply.)

A nurse is caring for a client who has dementia. The client is agitated and is having difficulty staying in his chair. Which of the following actions should the nurse take first?

A nurse is providing teaching to a client about preventing skin cancer. Which of the following client statements indicates a need for further teaching?

A nurse is preparing to administer penicillin IM to an adult client. Which of the following angles should the nurse use for injection into the client's ventrogluteal muscle?

A nurse is reviewing the medical record of a client who is to receive the first dose of cefoxitin via intermittent IV bolus. Which of the following findings should the nurse identify as a contraindication for the client to receive cefoxitin and report to the provider?

A nurse is assisting with the admission of a client who is about to have elective surgery. The client tells the nurse she feels anxious. Which of the following responses should the nurse make?