The RN is caring for James, an elderly man, in his home. The client’s son, Brad, is visiting and he plans to take James to the bank so that he can sign a Power of Attorney (POA) for his finances over to Brad. James tells the nurse that he is not ready for his son to take over as POA, but he doesn’t want to make him angry.
What should the nurse do next?

Assure the patient that his son has his best interest in mind.

The nurse has no accountability for this situation since it is not a clinical issue.

Notify the primary care physician that the patient can no longer care for himself.

Contact the department of aging to report suspected financial abuse.

Answer and Explanation

The Correct Answer is D

The nurse has a duty to protect the patient’s rights and well-being, and to report any signs of abuse or neglect. Financial abuse is defined as someone illegally or improperly using an elder’s money or belongings for their own personal use. It is a common form of elder abuse and can have serious consequences for the victim’s physical and mental health.

The nurse should not assume that the son has the patient’s best interest in mind (choice A), as this may not be the case.

The nurse should not ignore the situation or dismiss it as a non-clinical issue (choice B), as this would violate the nurse’s ethical and legal obligations. The nurse should not notify the primary care physician that the patient can no longer care for himself (choice C), as this may not be true and may infringe on the patient’s autonomy and dignity.

The nurse should respect the patient’s wishes and help him to exercise his rights and choices.

The nurse should also provide support and resources to the patient, such as counselling, legal aid, or social services.

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Correct Answer is D

Explanation

McBurney’s point is located one-third of the distance from the right anterior superior iliac spine to the umbilicus. This is where the base of the appendix is attached to the cecum, which is part of the large intestine. When the appendix becomes inflamed or infected, it causes pain in this area.

Choice A is wrong because the left lower quadrant is where the sigmoid colon and part of the small intestine are located.

These organs are not related to appendicitis.

Choice B is wrong because the left upper quadrant is where the stomach, spleen, and part of the pancreas are located.

These organs are also not related to appendicitis.

Choice C is wrong because the right upper quadrant is where the liver, gallbladder, and part of the small intestine are located. These organs can cause pain in this area if they have problems, but not appendicitis

A. Instruct the client to use pursed-lip breathing. B. Plan to have the client lay down for 1 hr after meals. C. Restrict the client’s fluid intake to less than 1 L/day. D. Encourage the client to use the upper chest for respiration.

Correct Answer is A

Explanation

Pursed-lip breathing is a technique that helps to slow down the breathing rate and keep the airways open longer. This improves gas exchange and reduces the work of breathing. Pursed-lip breathing also helps to prevent air trapping and hyperinflation of the lungs, which are common complications of COPD.

Choice B is wrong because laying down for 1 hour after meals can increase the pressure on the diaphragm and make breathing more difficult. It can also increase the risk of aspiration and reflux.

Choice C is wrong because restricting the client’s fluid intake to less than 1 L/day can lead to dehydration and thickening of secretions, which can obstruct the airways and impair gas exchange. Fluid intake should be adequate to maintain hydration and thin secretions.

Choice D is wrong because using the upper chest for respiration is a sign of inefficient breathing and respiratory distress.

It can increase the oxygen demand and cause fatigue. The client should be encouraged to use the diaphragm and abdominal muscles for respiration, which are more efficient and reduce the work of breathing.

Normal ranges for oxygen saturation are 95% to 100%, for arterial blood gas pH are 7.35 to 7.45, for PaCO2 are 35 to 45 mmHg, for PaO2 are 80 to 100 mmHg, and for HCO3 are 22 to 26 mEq/L.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In individuals who have appendicitis, the pain will typically localize to McBurney’s point. Which quadrant of the abdomen is McBurney’s point found?

Correct Answer is D

Explanation

A nurse is contributing to the plan of care for a client who has COPD. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is A

Explanation

A nurse is utilizing the cognitive domain of learning to teach a patient about the prevention of inflammation. Which of the following is an appropriate goal for this patient?

A nurse is caring for a patient with a BMI of. Appropriate nursing interventions include:

Signs of hemolytic anaemias include:

A nurse is caring for a client with chronic fatigue syndrome. Which of the following criteria were used to assist in making this diagnosis? Select all that apply.

A nurse is caring for a client who has a cloudy, opaque area over the lens of one eye. The nurse should identify that this is a manifestation of which of the following visual impairments?

A charge nurse is providing an in-service to a group of nurses on the different levels of illness prevention. The nurse should include which of the following as an example of secondary prevention?

A charge nurse is discussing evidence-based practice (EBP) with a newly licensed nurse. Which of the following information should the nurse include when discussing the hierarchy of evidence?

A client who is at risk for developing osteoporosis asks what can be done to decrease the risk of actually developing the disorder. Which intervention would be the most beneficial for this client?