A client in the final stages of terminal cancer tells the nurse: “I wish I could be just be allowed to die. I’m tired of fighting this illness. I have lived life a good life. I only continue my chemotherapy and radiation treatment because my family wants me to.” What is the best nurse’s best response?

Correct Answer: C

Rationale: The correct response is C: “Would you like to meet with your family and your physician about this matter?” Rationale: 1. Involving the family and physician ensures a collaborative decision-making process. 2. It respects the client's autonomy and involves them in the decision-making process. 3. It promotes open communication and support from loved ones. 4. It addresses the client's concerns about continuing treatment based on family wishes. Summary: A: Refers to psychological support, but the client's primary concern is medical treatment decisions. B: Involves religious support, which may not align with the client's beliefs or address the medical decision. D: Acknowledges the client's feelings but lacks a collaborative approach involving family and healthcare team.

Correct Answer: B

Rationale: The correct answer is B: Use two people to assist the patient. This is the safest option as it provides optimal support and stability for the patient during their first postoperative ambulation. Two people can help prevent falls, ensure proper body mechanics, and offer immediate assistance if needed. Using one person (choice A) may not provide enough support. Encouraging the patient to "dangle" (choice C) may increase the risk of orthostatic hypotension. Giving a narcotic before ambulation (choice D) can impair the patient's balance and coordination, increasing the risk of falls.

Correct Answer: D

Rationale: The correct answer is D: “Your heart is not an efficient pump.” This response is the best choice as it accurately describes heart failure, which is a condition where the heart is unable to pump blood effectively. This leads to symptoms such as fatigue, shortness of breath, and fluid retention. Explanation: 1. Choice A is incorrect because heart failure does not mean the heart stops; it means the heart is not functioning properly. 2. Choice B is incorrect because heart failure does not necessarily mean there is dead muscle tissue in the heart. 3. Choice C is incorrect because heart failure is not about pumping too much blood; it is about the heart's inability to pump blood efficiently, leading to circulation problems and other symptoms.

Correct Answer: B

Rationale: The correct answer is B because the internal mammary and internal thoracic arteries in the chest are commonly used for grafting due to their size, durability, and long-term patency. These arteries have a better track record for successful grafting procedures compared to the other options. The basic and cephalic veins in the arm (Option A) are typically used for venous procedures, not arterial grafting. The saphenous vein in the leg (Option C) is also commonly used for grafting, but the internal mammary and internal thoracic arteries are preferred for their better outcomes. The radial artery in the arm (Option D) is less commonly used for grafting compared to the internal mammary and internal thoracic arteries.

Correct Answer: B

Rationale: The correct answer is B because monitoring the site and progress of the infusion every hour is crucial to prevent complications like infiltration or infection in clients with hypertension. Choice A is incorrect as checking BP every hour is excessive. Choice C is incorrect as daily monitoring may not detect issues promptly. Choice D is incorrect as pulse rate monitoring is not directly related to IV fluid administration in this context. Monitoring the site and progress hourly ensures timely intervention if any issues arise.