A nurse is caring for a client who has a new diagnosis of a terminal illness. The client states, "I do not want any treatment. I would like to go home." Which of the following responses should the nurse make?

"I can refer you to hospice care, and they can help you at home."

"You should discuss this with your family before making a decision."

"Do you understand that, without treatment, you will die?"

"Don't you think you are giving up too soon?"

Answer and Explanation

The Correct Answer is A

The nurse should respect the client's autonomy and right to make decisions about their own care. Referring the client to hospice care is an appropriate response because it provides the client with support and care in their own home.

Options b, c, and d are not appropriate responses because they do not respect the client's autonomy.

Option b suggests that the client needs to discuss their decision with their family before making a decision, which may not be necessary or desired by the client.

Option c confronts the client with the reality of their illness in a potentially insensitive manner.

Option d suggests that the client is giving up too soon, which may not be an accurate or helpful assessment of the situation.

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Correct Answer is B

Explanation

Before administering enteral feedings via an NG tube, the nurse should check for gastric residual volume to ensure that the client is able to tolerate the feeding. If the residual volume is high, it may indicate delayed gastric emptying and the feeding may need to be delayed or the rate adjusted.

a. Encouraging the client to take sips of water may help maintain hydration, but it is not necessary prior to administering enteral feedings.

c. Flushing the tube with sterile 0.9% sodium chloride irrigation can help maintain patency of the tube, but it is not necessary prior to administering enteral feedings.

d. Encouraging the client to breathe deeply and cough can help clear secretions from the lungs, but it is not necessary prior to administering enteral feedings.

A. Use a cuﬀ with a width that is about 60% of the client's arm circumference. B. Apply the cuﬀ above the client's antecubital fossa. C. Have the client sit with his arm resting above the level of his heart. D. Release the pressure on the client's arm 5 to 6 mm per second.

Correct Answer is A

Explanation

When checking a client's blood pressure, the nurse should use a cuﬀ with a width that is about 60% of the client's arm circumference. This will help to ensure that the cuﬀ fits properly and provides an accurate reading.

Options b, c, and d are not correct. The cuﬀ should be applied over the client's brachial artery, which is located in the antecubital fossa. The client should sit with their arm resting at the level of their heart, not above it. The pressure on the client's arm should be released at a rate of 2 to 3 mm per second, not 5 to 6 mm per second.

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A nurse is caring for a client who has a new diagnosis of a terminal illness. The client states, "I do not want any treatment. I would like to go home." Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse take prior to administering the formula?

Correct Answer is B

Explanation

A nurse is preparing to check a client's blood pressure. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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