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A nurse is caring for a client whose child died from cancer. The client states, "It's hard to go on without him." Which of the following questions should the nurse ask the client first?

"What has helped you through difficult times in the past?"

"Has anyone in your family committed suicide?"

"Are you thinking about ending your life?"

"Is there anyone you would like involved in your care?"

Answer and Explanation

The Correct Answer is C

A. "What has helped you through difficult times in the past?": Important but not the priority in a potential crisis.

B. "Has anyone in your family committed suicide?": Relevant but not the first question.

C. "Are you thinking about ending your life?": Directly assesses the client's safety and risk for suicide.

D. "Is there anyone you would like involved in your care?": Supports coping but is not urgent.

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Correct Answer is A

Explanation

A. Place a warm, moist compress on the site: This helps reduce the inflammation associated with phlebitis by promoting blood flow to the affected area and easing discomfort.

B. Insert a new IV catheter distal to the discontinued IV site: Incorrect. The site with phlebitis should not be used for a new IV insertion. A new, unaffected site should be chosen.

C. Apply a pressure dressing at the IV site: Incorrect. A pressure dressing is not required for phlebitis unless there is active bleeding.

D. Express drainage from the IV site and send it to be cultured: Incorrect. Expressing drainage is not a standard practice for phlebitis unless there is an indication of infection and purulent drainage.

A. Blood pressure B. Temperature C. Potassium level D. WBC count E. Breath sounds

Correct Answer is ["B","D","E"]

Explanation

A. Blood pressure – The client's blood pressure of 114/56 mm Hg is within an acceptable range and does not indicate hypotension or hypertension.

B. Temperature – A temperature of 38.6°C (101.5°F) is indicative of fever, which is concerning in a client undergoing chemotherapy due to their increased risk of infection (febrile neutropenia). Prompt evaluation and intervention are necessary to prevent sepsis.

C. Potassium level – The client's potassium level of 3.6 mEq/L is within the normal range (3.5 to 5 mEq/L) and does not require immediate intervention.

D. WBC count – The client's WBC count has decreased to 3,800/mm³, which is below the normal range (5,000 to 10,000/mm³), indicating leukopenia. This places the client at a higher risk for infection, requiring close monitoring and potential interventions.

E. Breath sounds – The presence of crackles at the lung bases suggests possible pulmonary complications, such as fluid overload, infection (e.g., pneumonia), or early signs of acute respiratory distress syndrome (ARDS). This finding warrants further assessment and intervention.

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A nurse is caring for a client whose child died from cancer. The client states, "It's hard to go on without him." Which of the following questions should the nurse ask the client first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to remove an IV catheter from the arm of a client who has phlebitis at a peripheral IV site. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A nurse is reviewing the client's electronic medical record. Exhibits Which of the following findings require follow up? Select all that apply.

Correct Answer is ["B","D","E"]

Explanation

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