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A nurse is caring for an alert and oriented client who has terminal lung cancer. The nurse observes the client's family assisting with all ADLs. Which of the following rationales for self-care should the nurse communicate to the family on behalf of the client?

The client's sense of loss can be lessened through retaining dignity and control of certain areas of their life such as ADLs.

Allowing the client to function independently will strengthen their muscles and promote healing from the illness.

The client's decision in regards to their care should not influence their family's decision to assist with ADLs.

The ADLs can only be performed by a member of the healthcare team.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A. The rationale for self-care that the nurse should communicate to the client's family is that the client's sense of loss can be lessened through retaining dignity and control of certain areas of their life such as ADLs. Allowing the client to perform self-care activities independently, to the extent possible, promotes the client's autonomy and helps to preserve their selfesteem and sense of control over their life. As the client nears the end of life, it is important to respect their wishes and promote their comfort and well-being in every way possible.

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Correct Answer is C

Explanation

The correct answer is choice C, face. When beginning a complete bed bath, the nurse should first wash the client's face, followed by the arms, chest, abdomen, legs, perineal area, back, and then feet. Washing the face first is important to promote client comfort and hygiene, and also sets a positive tone for the rest of the bath. Additionally, washing the face before the perineal area helps to prevent cross-contamination of bacteria from the perineal area to the face.

A. Sit out of bed in the chair. B. Verbalize feelings about surgery at some point. C. Eat low sodium food. D. Identify the five major drug side effects before discharge tomorrow.

Correct Answer is D

Explanation

The correct answer is choice D. Identify the five major drug side effects before discharge tomorrow. A measurable client goal should be specific, observable, and

measurable. It should describe a behavior or outcome that the client can achieve. Identifying the five major drug side effects is specific and measurable. Sitting out of bed in a chair is too general, while verbalizing feelings about surgery at some point is not observable and not time-bound. Eating low sodium food is specific but not measurable.

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A nurse is caring for an alert and oriented client who has terminal lung cancer. The nurse observes the client's family assisting with all ADLs. Which of the following rationales for self-care should the nurse communicate to the family on behalf of the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is beginning a complete bed bath for a client. After preparing the client by removing the client's gown and placing a bath blanket over him, which of the following areas should the nurse wash first?

Correct Answer is C

Explanation

Which of the following is the best example of a measurable client goal? The client will:

Correct Answer is D

Explanation

A dietitian is providing an in-service for the nurses on a medical-surgical unit. During the in-service, the dietitian informs the group that there are six classes of nutrients, and three supply the body with energy. Which of the following are the three energy supplying nutrients?

A new perioperative nurse is being educated regarding surgical asepsis. What observations by the preceptor would indicate that there is a need for further education and reinforcement of the principles of asepsis?

A nurse is using the SOAP documentation format to chart on their patient in a systematic and organized way. When using SOAP, what sections would be present in the charting? Select all that apply.

A nurse is caring for a client who has a history of falling at their assisted living facility. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall?

The physician orders penicillin G 1,000,000 units IM. The label on the vial of powdered penicillin G reads to reconstitute with 1.6 mL of sterile water to achieve a concentration of 5,000,000 units/mL. How many mL will the nurse give to the client for the ordered dose?

A client is scheduled for a routine physical assessment at the neighborhood clinic. What should the nurse do when physically assessing the client's oxygenation status? Select all that apply.

A new patient is admitted to a medical unit with Clostridium difficile (C-diff). Which type of precautions or isolation should the nurse apply for this patient?