A nurse is caring for a client who is visibly upset and tearful about a recent terminal diagnosis. Which of the following responses should the nurse make?

"I'm going to contact your family so they can be with you."

"I will stay with you for a while."

"I'm sorry you have to deal with this."

"When you feel better, we'll talk about your treatment options."

Answer and Explanation

The Correct Answer is B

A. "I'm going to contact your family so they can be with you.": While involving family is important, the nurse should first provide emotional support to the client. It may feel abrupt to the client if the nurse immediately redirects the focus to others without acknowledging the client's current emotional state.

B. "I will stay with you for a while.": This is correct. Offering presence and emotional support by staying with the client is an appropriate response. It shows empathy and provides the client with comfort in a time of emotional distress.

C. "I'm sorry you have to deal with this.": This is less supportive. While it acknowledges the difficulty of the situation, it could unintentionally invalidate the client’s feelings by focusing on the nurse’s perspective rather than the client's experience.

D. "When you feel better, we'll talk about your treatment options.": This is not an appropriate response. It minimizes the client’s current emotional needs and may make the client feel that their feelings are not being prioritized. The focus should be on emotional support first.

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Correct Answer is A

Explanation

A. "I should keep my baby rear-facing in the car seat until she is 2 years old.": This is correct. The American Academy of Pediatrics recommends that infants and toddlers remain in a rear-facing car seat until they are at least 2 years old or until they reach the height and weight limits specified by the car seat manufacturer. Rear-facing provides the best protection for the baby's head, neck, and spine in the event of an accident.

B. "I should position the car seat's retainer clip at the level of my baby's belly button.": This is incorrect. The retainer clip should be positioned at armpit level, not at the belly button. This ensures the harness fits snugly and securely around the baby.

C. "I should enable the airbag when my baby is in the front seat of the car.": This is incorrect. Airbags should never be enabled when a baby is sitting in the front seat, as they can cause injury in the event of a collision. The baby should always be seated in the back seat of the car, as it is the safest location.

D. "I should place my baby in the car seat at a 90-degree angle.": This is incorrect. The car seat should be reclined at an angle of approximately 45 degrees to ensure the baby’s head does not fall forward, which could compromise breathing. A 90-degree angle is too upright and may be unsafe for a newborn.

A. Instruct the client to hold the drainage bag at waist height when ambulating. B. Coil the tubing on the bed above the collection bag. C. Collect a sterile specimen from the urinary drainage bag. D. Secure the tubing with adhesive tape to the lower abdomen.

Correct Answer is D

Explanation

A. Instructing the client to hold the drainage bag at waist height when ambulating is incorrect. The drainage bag should always be kept below the level of the bladder to prevent urine backflow, which can lead to infections (catheter-associated urinary tract infections - CAUTIs).

B. Coiling the tubing on the bed above the collection bag is incorrect. Tubing should be secured below bladder level without kinks or loops to allow for continuous urine drainage and prevent urinary stasis and infection.

C. Collecting a sterile specimen from the urinary drainage bag is incorrect. Urine in the drainage bag is not sterile and may contain bacteria, leading to inaccurate results. A specimen should be collected from the designated port on the catheter tubing using aseptic technique.

D. Securing the tubing with adhesive tape to the lower abdomen is correct. For male clients, securing the catheter to the lower abdomen prevents urethral trauma and tension. For female clients, the catheter is typically secured to the inner thigh to minimize movement and irritation.

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A nurse is caring for a client who is visibly upset and tearful about a recent terminal diagnosis. Which of the following responses should the nurse make?

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