A nurse on a medical-surgical unit is caring for a client who has a new diagnosis of terminal cancer. The client tells the nurse that they would like to go home to be with family and loved ones. Which of the following actions should the nurse take?
Contact the facility chaplain to visit with the client.
Explain the process of leaving the facility against medical advice.
Make a referral for social services.
The Correct Answer is C
A. Contacting the facility chaplain to visit with the client may be helpful for some clients who have spiritual needs or concerns, but it does not address the client's expressed desire to go home. The nurse should respect the client's wishes and preferences and not impose their own beliefs or values on them.
B. Explaining the process of leaving the facility against medical advice may discourage the client from pursuing their goal of going home and imply that they are making a wrong decision. The nurse should not judge or coerce the client, but rather provide them with information and support to make an informed choice.
C. Making a referral for social services is the best action for the nurse to take, as it will help the client access resources and services that can facilitate their discharge planning and home care arrangements. The social worker can also assist with financial, legal, or emotional issues that may arise from the terminal diagnosis.
D. Encouraging the client to continue with inpatient care may go against the client's wishes and values, and may cause them more distress and suffering. The nurse should respect the client's autonomy and dignity and support their quality of life goals.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Incorrect. The nurse should educate the parent on the importance of nebulizer treatments to deliver medications that thin and loosen mucus in the airways.
B. Incorrect. The nurse should advise the parent to contact the provider if the child has a fever, which could indicate an infection or inflammation in the lungs.
C. Correct. The nurse should initiate a request for a high-frequency chest compression vest, which is a device that vibrates the chest wall and helps mobilize mucus from the lungs.
D. Incorrect. The nurse should encourage the parent to support the child's participation in team sports, which can improve lung function and social skills.
Correct Answer is C
Explanation
A. Assessing fluid intake every 24 hr is important for a postoperative client, but it is not the priority action. The nurse should monitor fluid intake and output more frequently, such as every 8 hr or every shift, to detect any imbalances or complications.
B. Ambulating three times a day is beneficial for a postoperative client, but it is not the priority action. The nurse should encourage early and frequent ambulation to promote circulation, prevent thromboembolism, and enhance bowel function, but only after ensuring that the client is stable and has adequate pain control.
C. Assisting with deep breathing and coughing is the priority action for a postoperative client who had abdominal surgery. The nurse should help the client perform these exercises every 1 to 2 hr to prevent atelectasis, pneumonia, and respiratory failure, which are common and serious complications after abdominal surgery.
D. Monitoring the incision site for findings of infection is important for a postoperative client, but it is not the priority action. The nurse should inspect the wound for signs of infection, such as redness, swelling, warmth, drainage, or odor, but this can be done during routine dressing changes or as needed.
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