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A nurse is caring for a group of clients. In which of the following scenarios is the nurse acting as a client advocate?

The nurse files an incident report regarding a medication error.

The nurse provides wound care to a client at the time promised to the client.

The nurse declines to inform a client's neighbor about the client's prognosis.

The nurse refers a client who has chronic obstructive pulmonary disease for palliative care services.

Answer and Explanation

The Correct Answer is D

Answer: D. The nurse refers a client who has chronic obstructive pulmonary disease for palliative care services:

Rationale:

A) The nurse files an incident report regarding a medication error:

Filing an incident report about a medication error is an important action for ensuring safety and quality improvement within the healthcare setting. However, it is primarily a procedural and administrative task rather than an act of direct advocacy for an individual client's needs or rights.

B) The nurse provides wound care to a client at the time promised to the client:

Providing wound care as promised demonstrates reliability and adherence to care plans, which is essential for trust and effective nursing practice. While this action shows respect for the client's needs and preferences, it does not specifically address the broader role of advocacy, which often involves intervening on behalf of the client's best interests in more complex situations.

C) The nurse declines to inform a client's neighbor about the client's prognosis:

Maintaining client confidentiality by not sharing private information with unauthorized individuals is a fundamental aspect of ethical nursing practice. This action protects the client's privacy but is more about upholding legal and ethical standards than actively advocating for the client's overall well-being or specific needs.

D) The nurse refers a client who has chronic obstructive pulmonary disease for palliative care services:

Referring a client with chronic obstructive pulmonary disease (COPD) to palliative care services exemplifies client advocacy. This action recognizes the client's need for comprehensive support, focusing on improving quality of life, managing symptoms, and providing holistic care. It involves proactive steps to address the client's complex health needs, ensuring they receive appropriate and compassionate care beyond standard medical treatment.

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Correct Answer is A

Explanation

Choice A rationale:
The nurse should instruct the client to place cellular phones on the ear opposite the side of the pacemaker to minimize the risk of electromagnetic interference. Although the risk of interference is low with modern pacemakers, it is still a precautionary measure. Placing the phone on the ear opposite the pacemaker reduces the likelihood of any potential electromagnetic interaction.
Choice B rationale:
The instruction in choice B, "Avoid showering for the first 2 weeks following surgery,”. is not appropriate. There is no need for the client to avoid showering after pacemaker insertion. In fact, maintaining good hygiene is essential to prevent infection at the incision site. The client can take a shower, but they should avoid soaking the incision area and patting it dry afterward.
Choice C rationale:
The instruction in choice C, "Avoid heavy lifting for 1 week following insertion,”. is not the best option. The recommended timeframe to avoid heavy lifting after a pacemaker insertion is usually around 4 to 6 weeks. This duration allows the surgical site to heal properly and reduces the risk of dislodging the pacemaker leads or causing damage.
Choice D rationale:
The instruction in choice D, "Stand at least 2 feet away while using a microwave,”. is not directly related to pacemaker care. While it is generally recommended to maintain a safe distance from microwaves during use, this instruction is not specific to clients with pacemakers.

A. Hypertension. B. Weight gain. C. Fever. D. Hypoglycemia.

Correct Answer is C

Explanation

C. Fever:
Fever is a classic sign of fat overload syndrome. Fat overload syndrome occurs when the body is unable to metabolize the fat in the IV fat emulsion properly, leading to fat accumulation in tissues and organs. This can result in fever, which is one of the primary manifestations. Other signs can include respiratory distress, liver dysfunction, and changes in laboratory values, such as elevated triglycerides.

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A nurse is caring for a group of clients. In which of the following scenarios is the nurse acting as a client advocate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client who has a newly inserted permanent pacemaker. Which of the following instructions should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is assessing a client who is receiving IV fat emulsion therapy. Which of the following findings should the nurse identify as a manifestation of fat overload syndrome?

Correct Answer is C

Explanation

A nurse is caring for a client who is experiencing anxiety as well as numbness and tingling of the lips and fingers. The client's ABGs are pH 7.48, PCO2 30 mm Hg, HCO3 24 mEq/L, PaO2 85 mm Hg. Which of the following acid-base imbalances should the nurse identify that the client is experiencing?

A nurse is reviewing the ABGs of a client who has pneumonia. The nurse should identify which of the following findings is an indication of respiratory acidosis.

A nurse is caring for a client who has an NG tube to suction and is receiving IV fluids to maintain fluid volume balance. Which of the following findings should indicate to the nurse that this therapy is effective?

A nurse is providing teaching for a client about testicular cancer. Which of the following manifestations should the nurse instruct the client to monitor for during self-examination?

A nurse is caring for a client who is receiving mechanical ventilation. Which of the following actions should the nurse implement to decrease the client's risk for ventilator-associated pneumonia (VAP)? (Select all that apply.).

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A nurse is preparing to discharge a client who is postoperative following a total hip arthroplasty. Which of the following equipment should the nurse ensure that the client has available at home prior to discharge?

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