A home health nurse is conducting an initial home visit for a client who has terminal breast cancer. The client has two school-age children and a limited support system. Which of the following is the priority nursing action?

Inform the client of available community resources.

Assist the client in finding child care options.

Agree upon short-term goals for the client.

Ask the client about their understanding of the diagnosis.

Answer and Explanation

The Correct Answer is D

A. Inform the client of available community resources is an important action because the client will likely need additional support, such as hospice care, counseling, or child care services. However, before providing resources, the nurse must assess the client’s understanding of their diagnosis to ensure any interventions are tailored to their current needs and readiness.

B. Assist the client in finding child care options - While important, addressing community resources takes precedence as it may encompass finding child care options as well.

C. Agree upon short-term goals for the client - Establishing goals is important but may come after addressing immediate needs.

D. Ask the client about their understanding of the diagnosis is the priority action. Before any other interventions, the nurse must assess the client’s knowledge and perception of their condition. This foundational step allows the nurse to provide appropriate education, clarify any misconceptions, and ensure that all care planning aligns with the client’s needs, values, and readiness to engage in discussions about their care.

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Correct Answer is B

Explanation

A. The wall suction setting does not directly indicate the functioning of the NG tube.

B. Greenish-yellow drainage fluid may indicate the presence of bile in the stomach, suggesting

that the NG tube is not adequately draining gastric contents, which could indicate a malfunction.

C. An aspirate pH of 3 indicates gastric acidity, which is expected in the stomach and does not necessarily indicate a problem with NG tube function.

D. Abdominal rigidity may suggest intra-abdominal pathology but does not specifically indicate NG tube dysfunction.

A. Troponin 11.8 ng/mL B. Erythrocyte sedimentation rate (ESR) 17 mm/hr C. Human B-type natriuretic peptide 88 pg/ml. D. aPTT 80 seconds

Correct Answer is A

Explanation

A. Troponin is a protein released into the bloodstream when there is damage to the heart muscle (myocardium), such as during a heart attack. Elevated troponin levels indicate myocardial injury or damage, making this the correct choice for indicating myocardial damage.

B. Erythrocyte sedimentation rate (ESR) measures the rate at which red blood cells settle in a tube of blood. It is a non-specific marker of inflammation and is not specific to myocardial damage.

C. Human B-type natriuretic peptide (BNP) is released by the heart in response to increased pressure and volume. Elevated levels are indicative of heart failure, not necessarily myocardial damage.

D. Activated partial thromboplastin time (aPTT) measures the time it takes for blood to clot. It is used to monitor the effectiveness of anticoagulant therapy and is not specific to myocardial

damage.

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A home health nurse is conducting an initial home visit for a client who has terminal breast cancer. The client has two school-age children and a limited support system. Which of the following is the priority nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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