During the admission assessment of a terminally ill male client, he states that he is an agnostic. What is the best nursing action in response to this statement?

Correct Answer: B

Rationale: Documenting the client's statement in the spiritual assessment is the best nursing action in response to his disclosure of being an agnostic. This respects the client's beliefs and preferences, ensuring that care is tailored to his individual needs. It also demonstrates a commitment to providing holistic and patient-centered care.

Correct Answer: A

Rationale: Monitoring daily weights is an accurate method to assess the effectiveness of fluid replacement therapy because changes in weight reflect changes in fluid balance. Fluid volume deficit can be objectively evaluated by monitoring daily weights as it provides a more precise measurement of fluid status over time.

Correct Answer: C

Rationale: In the context of caring for a client with type 2 diabetes mellitus, evaluating hemoglobin A1c levels (Option C) is the most appropriate intervention to assess glycemic control. Hemoglobin A1c provides a measure of the average blood glucose levels over the past 2-3 months, giving a more comprehensive view of the client's long-term glycemic control compared to a single fasting blood glucose reading (Option A). Checking urine for ketones (Option B) is not a reliable method for assessing glycemic control as ketones may only be present when the client is experiencing diabetic ketoacidosis, which is a severe complication. Assessing the client's dietary intake (Option D) is important for overall diabetes management but does not directly assess glycemic control like hemoglobin A1c levels do. Educationally, understanding the significance of hemoglobin A1c in monitoring diabetes management is crucial for nurses. It is a valuable tool in assessing treatment effectiveness and guiding adjustments to the client's diabetes care plan. Educating healthcare providers on the importance of routine A1c testing can help in improving outcomes for clients with diabetes.

Correct Answer: B

Rationale: In the context of the digital removal of a fecal impaction, it is crucial for nurses to closely monitor the client for any adverse reactions or complications. The correct answer, option B, states that the pulse rate decreases from 78 to 52 beats/min. This is the reaction that would prompt the nurse to stop the procedure and take corrective action. A sudden significant decrease in pulse rate could indicate a potential complication such as vagal response or bradycardia, which could be life-threatening if not addressed promptly. Option A, the temperature increase from 98.8° to 99.0° F, is not directly related to the procedure and may be within normal variations. Option C, the respiratory rate increase from 16 to 24 breaths/min, could be a normal response to stress or discomfort during the procedure but does not indicate an immediate need to stop. Option D, the blood pressure increase from 110/84 to 118/88 mmHg, is also not a critical response that would require stopping the procedure. Educationally, this question highlights the importance of recognizing abnormal physiological responses during procedures and the need for prompt intervention to ensure patient safety. Understanding the significance of vital sign changes and their implications in clinical practice is essential for nurses providing direct patient care.

Correct Answer: B

Rationale: Positioning the client prone with a small pillow below the diaphragm helps maintain proper alignment and provides optimal pressure relief over the sacral area, reducing the risk of developing a pressure ulcer. This position redistributes pressure away from bony prominences, such as the sacrum, which is crucial in preventing ulcer formation in immobile clients.