A client is in the terminal stage of lung cancer. Outside the room, the client's spouse expresses to the nurse feelings of helplessness and a lack of hope for the future. How should the nurse respond?

Offer comfort that healing can happen at any point in time.

Offer strategies the spouse can use to provide comfort to the client.

Suggest that the spouse go home for a while and get some sleep.

Explain that the staff will strive to keep the client comfortable.

Answer and Explanation

The Correct Answer is D

Choice A reason: Offering comfort that healing can happen at any point in time may not be appropriate for a client in the terminal stage of lung cancer, as it may give false hope.

Choice B reason: Offering strategies to provide comfort to the client can be helpful, but it does not address the spouse's immediate emotional needs.

Choice C reason: Suggesting that the spouse go home to sleep may seem dismissive of the spouse's current emotional state and need for support.

Choice D reason: Explaining that the staff will strive to keep the client comfortable addresses the spouse's concern for the client's well-being and provides reassurance about the care being provided.

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Correct Answer is D

Explanation

Choice A reason: While the client's medical history and admission assessment provide valuable information, they do not directly measure the current pain experience.

Choice B reason: Vital signs can indicate pain but are not a definitive measure of pain severity as they can be influenced by other factors.

Choice C reason: The frequency of analgesic administration may suggest the level of pain control but does not measure the current pain intensity experienced by the client.

Choice D reason: Asking the client to describe the intensity of the pain is the most direct and effective way to assess pain severity. Pain is subjective, and the client's self-report is considered the gold standard for pain assessment.

A. Secure an allergy bracelet around the client's wrist. B. Notify the dietary department of the client's fruit allergy. C. Send a list of medication allergies to the pharmacy. D. Place a latex-free supply cart outside the client's room.

Correct Answer is A

Explanation

Choice A reason: An allergy bracelet provides immediate visual notification of the client's allergies to all healthcare personnel, which is crucial for preventing allergic reactions.

Choice B reason: Notifying the dietary department is important, but it does not have the same immediate impact on client safety as an allergy bracelet.

Choice C reason: Sending a list of medication allergies to the pharmacy is a necessary step, but it is secondary to providing immediate identification of the client's allergies.

Choice D reason: Placing a latex-free supply cart outside the room is a proactive measure to prevent exposure to latex, but the first step should be to ensure that the client's allergies are clearly identified for all staff.

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A client is in the terminal stage of lung cancer. Outside the room, the client's spouse expresses to the nurse feelings of helplessness and a lack of hope for the future. How should the nurse respond?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client's pain experience. Which nursing intervention is most effective in determining the severity of a client's pain?

Correct Answer is D

Explanation

During the admission assessment to the hospital, an adult client reports being allergic to latex, penicillin, and bananas. Which intervention should the nurse implement first?

Correct Answer is A

Explanation

The nurse receives a report that a patient with an indwelling urinary catheter has an output of 150 mL for the previous 8-hour shift. Which intervention should the nurse implement first?

The nurse is performing a routine dressing change for a client with a stage 3 pressure injury that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?

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

A patient with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the patient's fluid balance?

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?

A client with emphysema tells the nurse that sitting upright in bed makes breathing easier. Which instruction is most important for the nurse to provide the assigned unlicensed assistive personnel (UAP)?

When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. Which action should the nurse take next?