The hospice nurse is teaching the family of a client receiving palliative care at home how to provide care. Which instruction should the nurse provide?

Report any change in urine color.

Maintain in high Fowler's position.

Keep mucous membranes moist.

Record the client's daily weights.

Answer and Explanation

The Correct Answer is C

Choice A reason: Reporting any change in urine color is important but not specific to the provision of palliative care at home.

Choice B reason: Maintaining in high Fowler's position is not always necessary and may not be comfortable for all clients, especially in a palliative care setting.

Choice C reason: Keeping mucous membranes moist helps prevent discomfort and is a key part of providing compassionate end-of-life care.

Choice D reason: Recording the client's daily weights is less relevant in palliative care, where the focus is on comfort rather than ongoing medical assessments.

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

Explanation

Choice A reason: Shaking that affects a child's handwriting could indicate a neurological issue or other medical conditions that require immediate attention. It's essential for teachers to report such observations to the school nurse for proper assessment and intervention.

Choice B reason: Excessive thirst and frequent urination can be signs of diabetes, especially in children. Early detection and management are crucial for the child's health, making it important for teachers to report these symptoms.

Choice C reason: While refusal to complete homework could be related to behavioral or social issues, it is not typically a medical concern that requires the school nurse's intervention unless accompanied by other signs of distress or health problems.

Choice D reason: Bruises could be common in children due to their active nature, especially after a weekend. However, unless there is a pattern or other concerning signs of abuse or a medical condition, bruises alone may not necessitate a referral to the school nurse.

Choice E reason: Sunburn with blisters is a sign of a second-degree burn, which can be serious, especially in children. It is important for teachers to report this to the school nurse so that the child can receive proper care and parents can be advised on treatment and prevention.

A. Urinary output of 30 to 60 mL/hr. B. Magnesium level. C. Size of the IV catheter. D. Serum glucose level.

Correct Answer is A

Explanation

Choice A reason: Before administering IV fluids containing potassium chloride, it is crucial to ensure that the client has adequate urinary output, typically between 30 to 60 mL/hr. This indicates good kidney function, which is necessary for the excretion of potassium to prevent hyperkalemia, a potentially life-threatening condition.

Choice B reason: While magnesium levels can affect potassium levels, they are not the most critical assessment before potassium infusion. However, it is important to monitor magnesium levels as part of the overall electrolyte balance, especially in diabetic ketoacidosis.

Choice C reason: The size of the IV catheter is important for administration purposes, but it is not the most critical assessment data before starting potassium infusion. The catheter size affects the flow rate and comfort during infusion but does not impact the decision to start the infusion.

Choice D reason: Serum glucose level is a vital parameter to monitor in diabetic ketoacidosis, but it is not the most critical assessment before starting potassium infusion. The primary concern with potassium infusion is kidney function, as assessed by urinary output.

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The hospice nurse is teaching the family of a client receiving palliative care at home how to provide care. Which instruction should the nurse provide?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The school nurse is preparing a presentation for elementary school teachers to inform them about when a child should be referred to the school clinic for further follow-up. The teachers should be instructed to report which situation(s) to the school nurse? Select all that apply.

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

Explanation

A client with type 1 diabetes mellitus (DM) is admitted in diabetic ketoacidosis. Treatment is initiated, and the nurse is preparing to administer IV fluids containing potassium chloride. Which assessment data is most important for the nurse to obtain before starting the infusion?

Correct Answer is A

Explanation

A client with cirrhosis of the liver reports a 5 lb (2.3 kg) weight gain within the last week during a physical assessment. Which assessment finding correlates with the client's report?

The nurse implements a primary prevention program for sexually transmitted diseases in a nurse-managed health center. Which outcome indicates that the program was effective?

Which is the primary goal when planning nursing care for a client with degenerative joint disease (DJD)?

When performing suctioning for a client with a tracheostomy, which action should the nurse include?

Patient Data Exhibits The nurse reviews the assessment findings along with the physician orders. Which immediate interventions would the nurse initiate? Select all that apply.

A client tells the nurse of concerns about possibly having a stomach ulcer because the client is experiencing heartburn and a dull gnawing pain that is relieved by eating. Which is the best response by the nurse?

Patient Data Exhibits The nurse reviews the post catheterization orders. Which two orders would the nurse question?