A nurse is caring for a client who expresses feeling overwhelmed that their partner has alcohol use disorder and has been unable to keep a job for longer than 3 months. Which of the following is an appropriate response by the nurse?

“I'm sure your situation will get better with time."

"It must be terrible to be in this situation."

"If I were you, I would talk with the hospital chaplain."

“Tell me what you have done in the past to cope with your problems.”

Answer and Explanation

The Correct Answer is D

A. “I'm sure your situation will get better with time." This response is dismissive and does not acknowledge the client’s feelings. It provides false reassurance rather than support.

B. "It must be terrible to be in this situation." While this statement attempts empathy, it may sound judgmental or patronizing rather than encouraging meaningful discussion.

C. "If I were you, I would talk with the hospital chaplain." This response assumes what the client should do rather than exploring their current coping mechanisms. It does not encourage self-reflection.

D. “Tell me what you have done in the past to cope with your problems.” This response uses therapeutic communication by allowing the client to reflect on past coping strategies and explore potential solutions.

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Correct Answer is B

Explanation

A. Initiate a new IV line below the original insertion site. – If phlebitis or infection is present, a new IV should be placed in another limb or at a site above the previous insertion, not below.

B. Discontinue the infusion. – The first step in treating suspected phlebitis or IV infiltration is stopping the infusion to prevent further tissue damage.

C. Raise the head of the bed. – Elevating the head of the bed is not relevant in managing IV site complications.

D. Obtain a culture from the area of the insertion site. – Cultures are not necessary unless infection is suspected and prescribed by a provider.

A. Bradypnea B. Restlessness C. Hypertension D. Tachycardia

Correct Answer is D

Explanation

A. Bradypnea: Bradypnea (slow breathing) is not a typical late sign of hypoxia. Instead, clients with worsening hypoxia often develop tachypnea (rapid breathing) as the body tries to compensate for low oxygen levels.

B. Restlessness: Restlessness is an early sign of hypoxia, not a late one. It occurs due to inadequate oxygenation of the brain, leading to agitation and confusion.

C. Hypertension: Hypertension can be an early response to hypoxia as the body attempts to increase oxygen delivery. However, as hypoxia progresses, blood pressure may drop due to worsening oxygen deprivation.

D. Tachycardia: Tachycardia (increased heart rate) is a late sign of hypoxia. The heart compensates for low oxygen levels by increasing cardiac output. However, if untreated, hypoxia can progress to bradycardia and cardiac arrest.

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A nurse is caring for a client who expresses feeling overwhelmed that their partner has alcohol use disorder and has been unable to keep a job for longer than 3 months. Which of the following is an appropriate response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing the IV infusion site of a client who reports pain. The site is swollen and there is warmth along the course of the vein. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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