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 A

Explanation

A. Propranolol is a beta-blocker used to control blood pressure and heart rate. However, the nurse has a hold order for propranolol if the apical pulse (heart rate) is less than 50 beats per minute. The nurse documented a heart rate of 42 bpm at 0815, which falls below the hold parameter for propranolol. Administering propranolol in this case could worsen the client's bradycardia (slow heart rate) and therefore requires an incident report.
B. Pantoprazole is a proton pump inhibitor and doesn't have a direct impact on heart rate within the usual therapeutic range.
C. Lovastatin is a cholesterol medication and wouldn't cause a significant drop in heart rate at this dosage.
D. While morphine can slow the heart rate, it's typically used for pain management and may be necessary for the client's comfort. However, the nurse should monitor the respiratory rate closely due to potential respiratory depression.
E. Cefuroxime is an antibiotic and wouldn't significantly affect heart rate.

A. A client who is being discharged to a long-term care facility B. A client who is postoperative following a lobectomy and has a chest tube C. A client who needs teaching about insulin self-administration D. A client who needs teaching prior to initiating cardiac rehabilitation activities

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.

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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 is caring for a client. Exhibits The nurse reviews the medication administration record following the 0815 assessment findings. Which of the following administered medications would require an incident report?

Correct Answer is A

Explanation

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 preparing to administer 10 units of regular insulin and 20 units of NPH insulin to a client who has diabetes mellitus. When mixing the two types of insulin, which of the following actions should the nurse take first?

A nurse on the medical-surgical unit is conducting a fall risk assessment for four clients. The nurse should identify that which of the following clients is the greatest risk for a fall?

A nurse is caring for a group of clients. Which of the following clients should the nurse refer to a social worker? (Select all that apply.)

A nurse is planning care for a client who has leukemia and a platelet count of 130,000/mm3. Which of the following interventions should the nurse include in the plan of care?

A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the client's restored rhythm is symptomatic bradycardia?

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 monitoring a client who is on telemetry. Which of the following findings on the ECG strip should the nurse recognize as normal sinus rhythm?

Exhibits The nurse inspects the airway. There is no visible trauma, and the airway appears to be patent. What other assessment items are included in the primary survey? Select all that apply.