What is the nurse’s first action if a client with leukemia becomes disoriented and complains of frequent headaches?

Correct Answer: A

Rationale: The correct answer is A: Call the physician. In this scenario, the nurse should prioritize the client's safety and well-being by promptly notifying the physician about the client's sudden change in condition. Disorientation and frequent headaches in a leukemia patient could signal a serious complication, such as central nervous system involvement, which requires immediate medical intervention. Calling the physician ensures timely assessment and appropriate management. B: Documenting the patient's status is important but not the first action in this critical situation. C: Oxygen treatment may not be indicated based on the client's symptoms and needs further assessment by the physician. D: Raising the side rails is not directly addressing the client's symptoms and does not provide immediate medical attention.

Correct Answer: C

Rationale: The correct answer is C: Teacher. Nurses provide health teaching to educate and empower individuals to make informed choices for behavior change. Teaching involves providing information, skills, and resources to promote positive health outcomes. Caregiver (A) involves providing physical care. Communicator (B) focuses on conveying information. Change Agent (D) refers to facilitating and supporting change but doesn't encompass the educational aspect essential for behavior change.

Correct Answer: B

Rationale: The correct answer is B because asking the client to take a deep breath and hold it before removing the NGT helps prevent aspiration of the tube contents into the lungs. This action creates positive pressure in the chest, reducing the risk of aspiration. A: Confirming the physician's order is important but not directly related to the physical act of removing the NGT. C: Pinching the tube with a gloved hand is unnecessary and may cause discomfort or damage to the tube. D: Asking the client to exhale while removing the tube may increase the risk of aspiration as it creates negative pressure in the chest.

Correct Answer: A

Rationale: The correct answer is A because a normal oxygen saturation range is between 95-98%. This range indicates adequate oxygen levels in arterial blood. Choice B is incorrect because oximetry measures oxygen saturation of arterial blood, not venous blood. Choice C is incorrect as fasting is not required for pulse oximetry. Choice D is incorrect as pulse oximetry is a non-invasive tool used for quick oxygen saturation monitoring, not a replacement for arterial blood gas analysis.

Correct Answer: B

Rationale: The correct answer is B: Decrease PN rate to 50 mL/hour. This is because as Elise transitions to solid food, her need for parenteral nutrition will decrease. Decreasing the PN rate to 50 mL/hour gradually weans her off PN while ensuring she is still receiving some nutrition. Choice A is incorrect as abruptly discontinuing PN can lead to nutritional deficiencies and potential complications. Choice C is incorrect as starting normal saline is unrelated to the weaning process from PN. Choice D is incorrect as continuing the current infusion rate would not facilitate the transition to solid food.