A client is admitted with shortness of breath and hemoptysis. After several tests, the healthcare provider informs the client that the medical diagnosis is stage 4 breast cancer. The client tells the nurse about the decision not to inform the family about the diagnosis. Which intervention should the nurse implement?

Notify the health department of the client's condition.

Advise the client to weigh all possible outcomes prior to the decision.

Suggest to the family the value of genetic screening.

Explain that the family has a right to know of potential health problems.

Answer and Explanation

The Correct Answer is B

A)   This intervention is not appropriate because it violates the client's privacy and confidentiality. The health department does not need to be notified of the client's condition, as breast cancer is not a communicable disease or a public health threat. The nurse should respect the client's wishes and only share information with authorized persons or agencies.
B)   This intervention is appropriate because it respects the client's autonomy and encourages informed decision-making. The nurse should advise the client to consider the benefits and risks of disclosing or withholding the diagnosis from the family, and how it may affect their relationships and support systems. The nurse should also provide relevant information and resources to help the client make an informed choice.
C)   This intervention is not appropriate because it contradicts the client's decision and may cause confusion or distress for the family. The nurse should not suggest genetic screening to the family without the client's consent, as this may imply that they are at risk of developing breast cancer or other genetic disorders. The nurse should also avoid giving unsolicited advice or opinions that may interfere with the client's autonomy.
D)   This intervention is not appropriate because it imposes the nurse's values and beliefs on the client. The nurse should not explain that the family has a right to know of potential health problems, as this may imply that the client is wrong or selfish for withholding the diagnosis. The nurse should acknowledge and respect the client's perspective and preferences, and support them in coping with their condition.

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Correct Answer is A

Explanation

Choice A reason: This client may have an infection or sepsis, which are life-threatening complications of surgery. The nurse should assess the client's vital signs, wound appearance, and laboratory results, and notify the physician immediately.

Choice B reason: This client has a chest tube to drain the pleural fluid and re-expand the lung. The amount of drainage is within normal limits and does not indicate an emergency. The nurse should monitor the client's respiratory status, oxygen saturation, and chest tube function.

Choice C reason: This client has a gunshot wound that may have caused tissue damage and bleeding. The dressing with 2 cm-sized dark red drainage may indicate fresh bleeding, but it is not excessive. The nurse should check the dressing for signs of infection, change it as ordered, and report any changes to the physician.

Choice D reason: This client has a Jackson-Pratt drain to collect the fluid from the surgical site after a mastectomy. The amount of serosanguineous fluid is expected and does not indicate a problem. The nurse should empty and measure the drain output, record it, and report any abnormalities to the physician.

A. Call the hospital operator to determine if this is indeed a real emergency or a fire drill. B. Instruct the clients' family members to stay in the visitor waiting area until further notice. C. Direct the nursing staff to evacuate the clients using the stairs in a calm and orderly manner. D. Tell the staff to keep all clients and visitors in the client rooms with the doors closed.

Correct Answer is D

Explanation

Choice A Reason: This action is not a priority, as it may delay the response to a potential fire. The charge nurse should assume that the fire alarm is real and act accordingly.

Choice B Reason: This action may expose the clients' family members to smoke or fire, as the visitor waiting area may not be safe. The charge nurse should ensure that everyone is in a protected area.

Choice C Reason: This action may be dangerous, as the stairs may be filled with smoke or fire. The charge nurse should follow the hospital's fire safety protocol, which usually involves closing doors, windows, and vents to prevent the spread of fire.

Choice D Reason: This action is the most appropriate, as it follows the RACE acronym for fire safety: Rescue anyone in immediate danger, Alarm by activating the fire alarm system, Contain by closing doors and windows, and Extinguish or evacuate as directed.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse receives a change-of-shift report from the prior nurse assigned to a group of clients on a post-surgical unit. Which client requires the most immediate intervention by the nurse?

Correct Answer is A

Explanation

The fire alarm goes off while the charge nurse is receiving the shift report. Which action should the charge nurse implement first?

Correct Answer is D

Explanation

Which staff assignment, made by the primary nurse, requires the most immediate follow-up action by the charge nurse on a medical unit?

The charge nurse of a critical care unit must transfer a client to a general unit to make a bed available for an incoming trauma client. Based on the information provided, which client is best for the nurse to recommend for transfer to the general unit?

An adult woman with metastatic pancreatic cancer has requested that no heroic measures are implemented to save her life. Instructions from the healthcare provider have been received to transfer the client to a palliative care room. Which action is most important for the nurse to take first?

A fire is reported in the kitchen on the first floor of a three-floor community hospital, and the operator notifies the charge nurse on the third floor to start evacuation procedures. Which intervention should the charge nurse implement?

The smell of cigarette smoke is coming from a client's bathroom. Which action should the nurse implement first?

A client with tachycardia and hypotension presents to the emergency department (ED) reporting severe vomiting and diarrhea for three days. Which action is most important for the nurse to implement?