The nurse has agreed to serve as a client's advocate at the meeting of the hospital ethics committee, which was called to address an ethical dilemma involving the client. To successfully represent the client, what action is essential for the nurse to take?

Develop self-awareness of the nurse's personal values to avoid imposing these values on the client.

Challenge members of the healthcare team whose opinions differ from the wishes of the client.

Educate the client about current nursing literature findings related to the client's ethical dilemma.

Listen to the ethics committee discussions and then inform the client what actions should be taken.

Answer and Explanation

The Correct Answer is A

A. It is essential for the nurse to develop self-awareness of their personal values to avoid imposing these values on the client. As an advocate, the nurse's primary role is to represent the client's wishes and ensure they are respected, regardless of the nurse's personal beliefs or values.
B. While challenging differing opinions may sometimes be necessary, it is more important to ensure the client's wishes are clearly communicated rather than simply opposing differing views.
C. Educating the client on relevant nursing literature is not the primary role of advocacy in this context. The focus should be on the client’s values and wishes rather than on influencing them with professional literature.
D. Listening to discussions is important, but the nurse's role as an advocate is to ensure the client's voice is heard during the discussions, rather than informing the client of decisions after the fact.

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Correct Answer is B

Explanation

A. White blood cell count is related to immune function and is not directly affected by water intoxication.
B. Serum sodium levels are the primary concern in cases of water intoxication. Excessive water intake can dilute the sodium in the blood, leading to hyponatremia, which can cause confusion, seizures, and other serious complications.
C. While serum potassium levels are important for overall electrolyte balance, they are not as immediately affected by water intoxication as sodium levels are.
D. Creatinine clearance is a measure of kidney function and does not directly relate to the immediate risks associated with water intoxication.

A. Instruct the client to use guided imagery and slow rhythmic breathing. B. Place a hot water circulation device, such as an Aqua K pad, to the operative site. C. Tune to a television show or easy listening music to provide distraction. D. Provide at least 20 minutes of back massage and gentle effleurage.

Correct Answer is A

Explanation

A. Guided imagery and slow rhythmic breathing are effective techniques for managing moderate pain and can help reduce the perception of pain by promoting relaxation. These methods can be used in conjunction with pain medication to enhance overall pain management.
B. Applying a hot water circulation device may not be appropriate for postoperative pain, as heat could interfere with healing or cause complications. The focus should be on pain management strategies that are safe for the surgical site.
C. While distraction methods like television or music can help, they are generally less effective for managing moderate pain compared to relaxation techniques and additional pain management strategies.
D. Providing a back massage may not be appropriate immediately after thoracic surgery, as it could cause discomfort or interfere with the surgical site. Effective pain management should prioritize safe and recommended interventions.

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The nurse has agreed to serve as a client's advocate at the meeting of the hospital ethics committee, which was called to address an ethical dilemma involving the client. To successfully represent the client, what action is essential for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses that a client who is disoriented drank eight glasses of water in two hours and is continuing to drink excessive amounts of water. Because the nurse is concerned about water intoxication, which laboratory value should the nurse monitor?

Correct Answer is B

Explanation

A client who is 2 days postoperative for thoracic surgery is reporting incisional pain 2 hours after receiving pain medication. The client rates the pain as 5 on a pain scale of 1 to 10. After placing a call to the healthcare provider, which action should the nurse implement?

Correct Answer is A

Explanation

The nurse observes that a client on a clear liquid diet has a cup of coffee on the breakfast tray. Which action should the nurse implement?

The healthcare provider prescribes two doses of an antihypertensive medication for a client. Before administering the second dose, the nurse obtains a blood pressure measurement of 80/50 mm Hg. Which action should the nurse take?

The nurse notes that a client has cyanosis of the toes and fingertips. Which vital sign should the nurse obtain first?

The nurse notes that a client has cyanosis of the toes and fingertips. Which vital sign should the nurse obtain first?

The nurse knows that skin turgor changes with age. Which intervention is most helpful in dealing with normal aging changes of the skin?

While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. Which action should the nurse take in response to this finding?

To assess a client's dorsalis pedis pulse, the nurse applies firm pressure over the top of the foot between the extension tendons of the great and first toes, but does not feel a pulsation. Which action should the nurse take next?