A client's spouse has just learned of the client's terminal illness. The spouse is sitting in the corner of the client's room crying, and says to the nurse, "I feel as if I'm already so alone." Which action should the nurse take first?

Explain that alternative treatment options may be helpful.

Remind the spouse that the client may still live a long time.

Offer reassurance that the spouse is not alone.

Encourage the spouse to share their feelings.

Answer and Explanation

The Correct Answer is C

C. The first action the nurse should take is to offer reassurance to the spouse that they are not alone. This statement acknowledges the spouse's emotional distress and provides comfort and support during a difficult time. It also validates the spouse's feelings of loneliness and acknowledges the importance of their presence and support for the client.

A and B focus on the client's illness or prognosis, which may not be the immediate concern for the spouse at this moment.

D, while valuable, may come after the initial reassurance to create a supportive environment for the spouse to share their feelings when they feel ready.

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Correct Answer is B

Explanation

A. Using an oral airway can be appropriate in some situations to keep the mouth open and facilitate oral care, especially in an unconscious client. This helps prevent biting and allows for easier access to the oral cavity. Therefore, this action does not indicate a need for additional training.

B. Placing an unconscious client in a supine position for oral care can be inappropriate, as it increases the risk of aspiration, especially if there are secretions in the mouth. It is generally safer to position the client in a lateral position to minimize this risk. This action may indicate a need for additional training.

C. Testing for a gag reflex before performing oral care is a standard precaution, especially for unconscious clients. This helps prevent aspiration and ensures the safety of the client during the procedure.

D. Suctioning secretions from the posterior pharynx is an appropriate action to maintain airway patency and prevent aspiration, especially for unconscious clients who may have difficulty managing their secretions.

A. Massage the site gently after injection. B. Ensure bevel of the needle is pointing up. C. Hold the syringe perpendicular to the skin. D. Select upper arm as the injection site.

Correct Answer is B

Explanation

B. The needle should be inserted with the bevel facing up (visible through the skin). The goal is to deposit the medication into the epidermal layer (not subcutaneous tissue).

A. Massaging the site after injection can cause the medication to spread beyond the intended area, leading to inaccurate results or potential complications.

C. The correct angle for an intradermal injection is 5 to 15-degree angle. This angle allows for proper placement of the medication just below the epidermis.

D. Intradermal injections are usually administered on the forearm or the upper back, where the skin is thin and easily lifted to create a wheal.

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A client's spouse has just learned of the client's terminal illness. The spouse is sitting in the corner of the client's room crying, and says to the nurse, "I feel as if I'm already so alone." Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes a practical nurse (PN) performing oral care on an unconscious client. Which action by the PN indicates to the nurse the need for additional training?

Correct Answer is B

Explanation

The nurse is administering an intradermal (ID) injection to a client. Which action should the nurse take?

Correct Answer is B

Explanation

A client is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurse implement?

It is most important for the nurse to recalculate the Braden scale score for a client who has developed which problem?

The nurse assesses an older adult woman's ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that her posture is upright, and her gait is smooth and steady. Which action should the nurse take next?

Which client assessment should the nurse perform during nasopharyngeal suctioning?

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

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