A nurse is planning care for a client who wants to quit smoking. Which of the following actions should the nurse plan to take first?

Implement activities that promote the client's self-esteem.

Offer a list of smoking cessation support groups.

Provide education about the dangers of smoking.

Determine the client's coping methods.

Answer and Explanation

The Correct Answer is D

Rationale:

A. Implement activities that promote the client's self-esteem: While boosting self-esteem can support smoking cessation, it is not the first priority. The nurse must first assess the client’s current coping strategies to tailor the cessation plan.

B. Offer a list of smoking cessation support groups: Providing resources is helpful, but without assessing the client’s needs and coping methods first, the support may not be appropriately matched to the client’s situation.

C. Provide education about the dangers of smoking: Education is important, but most clients are already aware of the health risks. Effective teaching requires first understanding the client's motivation and coping mechanisms.

D. Determine the client's coping methods: Assessment is always the initial step in the nursing process. Identifying how the client currently manages stress will help the nurse create an individualized and effective cessation plan.

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Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

Rationale for correct choices:

Obtain IV access: The client has hypotension (BP 90/50 mm Hg), tachycardia (HR 118/min), and significant anemia (Hgb 9.1 g/dL, Hct 27%), all of which suggest possible active gastrointestinal bleeding. Establishing IV access is a priority to allow rapid fluid resuscitation or blood product administration as needed.
Prepare for a blood transfusion: Given the positive hemoccult stool, anemia, and vital sign changes, the client may require a blood transfusion to restore hemodynamic stability and oxygen-carrying capacity. Preparing for transfusion ensures timely intervention in case of worsening blood loss.

Rationale for incorrect choices:

Call the surgical suite to notify that the client is arriving STAT: While the client is scheduled for endoscopy, immediate stabilization takes priority over notifying the surgical suite. The client’s hemodynamic status must be addressed first to prevent deterioration.
Recheck the client's oxygen saturation: The client’s oxygen saturation is 98% on room air, which is within normal limits. Rechecking is not immediately necessary and does not address the urgent need for stabilization.
Place the client in a supine position with feet elevated: Although elevating the feet can help improve perfusion temporarily, it does not treat the underlying anemia or hypotension and is less urgent than establishing IV access and preparing for transfusion.
Offer oral fluids: Oral intake is contraindicated in a client at risk for endoscopy and possible GI bleeding. Fluids could increase the risk of aspiration and do not address hemodynamic instability.
Administer PRN antacids: Antacids may provide minor symptom relief but do not treat active blood loss or stabilize the client before endoscopy.
Document vital signs: Documentation is important but secondary to immediate interventions that address the client’s hypotension and potential hemorrhage.

A. Raise the side rails up when the client is in bed. B. Place the bedside table at the foot of the bed. C. Keep the television on during the night. D. Assist the client to the toilet frequently.

Correct Answer is D

Explanation

A. Raise the side rails up when the client is in bed: Full side rails can increase the risk of entrapment and injury for clients with dementia. They are not recommended as a routine safety measure unless individually assessed and ordered.

B. Place the bedside table at the foot of the bed: Placing furniture at the foot of the bed can create obstacles and increase the risk of trips and falls. The environment should be arranged to allow safe, unobstructed mobility.

C. Keep the television on during the night: Continuous noise, such as a TV, can cause agitation or confusion in clients with dementia, increasing the risk of disorientation and injury. Quiet, calming environments are preferred.

D. Assist the client to the toilet frequently: Clients with dementia are at increased risk for falls due to urgency, confusion, or impaired mobility. Frequent toileting assistance reduces the risk of incontinence-related hazards and falls, promoting safety and dignity.

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A nurse is planning care for a client who wants to quit smoking. Which of the following actions should the nurse plan to take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is obtaining the client's vital signs prior to an endoscopy. Exhibits Complete the following sentence by using the list of options The nurse should first anticipate to dropdown then dropdown.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

A nurse in a long-term care facility is admitting a client who has dementia. Which of the following actions should the nurse take to reduce the risk for client injury?

Correct Answer is D

Explanation

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