When the nurse enters the room to change the dressing of a male client with cancer, he asks, 'Have you ever been with someone when they died?' What is the nurse's best response to him?

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Question 1 of 5

When the nurse enters the room to change the dressing of a male client with cancer, he asks, 'Have you ever been with someone when they died?' What is the nurse's best response to him?

Correct Answer: A

Rationale: The correct answer is A because it shows empathy and encourages open communication. The nurse acknowledges the client's question and offers support by asking if they have any concerns. This response demonstrates active listening and shows the nurse is willing to address the client's emotional needs. Choice B is incorrect as it dismisses the client's question and focuses solely on the task at hand, lacking empathy. Choice C is incorrect as it provides a general statement about previous experiences without directly addressing the client's inquiry. Choice D is incorrect as it deflects the question and does not actively engage with the client's emotional concerns.

Question 2 of 5

A 9-year-old received a short arm cast for a right radius. To relieve itching under the child's cast, which instructions should the nurse provide to the parents?

Correct Answer: A

Rationale: The correct answer is A: Blow cool air from a hair dryer under the cast. This method helps to relieve itching by providing airflow without causing damage to the cast or skin. It is safe and effective. Choice B: Twisting the cast back and forth may cause discomfort or injury to the child's arm. Choice C: Shaking powder into the cast can create a mess and may lead to skin irritation or infection. Choice D: Pushing a pencil under the cast edge can cause damage to the skin or lead to complications.

Question 3 of 5

What assessment technique should the nurse use to monitor a client for a common untoward effect of phenytoin (Dilantin)?

Correct Answer: B

Rationale: The correct answer is B: Inspection of the mouth. Phenytoin can cause gingival hyperplasia as a common untoward effect. By inspecting the mouth regularly, the nurse can assess for signs of this side effect such as swollen or bleeding gums. Bladder palpation (A) is not relevant to monitoring phenytoin side effects. Blood glucose monitoring (C) is not typically associated with phenytoin use. Auscultation of breath sounds (D) is not directly related to monitoring for phenytoin side effects.

Question 4 of 5

When administering an intramuscular injection containing 3 ml of a painful medication, which intervention should the nurse implement?

Correct Answer: C

Rationale: The correct answer is C: Select a large, deep muscle mass. This is because using a large, deep muscle mass ensures proper absorption and distribution of the medication, reducing the risk of tissue damage or irritation. Rationale: 1. Instilling the medication quickly (Choice A) can cause discomfort and increase the risk of tissue trauma. 2. Inserting the needle slowly (Choice B) can also lead to pain and discomfort for the patient. 3. Using a short, small gauge needle (Choice D) may not reach the deep muscle mass and can cause inadequate absorption of the medication. In summary, selecting a large, deep muscle mass ensures optimal medication delivery and minimizes discomfort and tissue damage compared to the other choices.

Question 5 of 5

The nurse is making assignments for a new graduate from a practical nursing program who is orienting to the unit. Because the unit is particularly busy this day, there will be little time to provide supervision of this new employee. Which client is the best for the nurse to assign to this newly graduated practical nurse?

Correct Answer: A

Rationale: The correct answer is A: Whose discharge has been delayed because of a postoperative infection. This assignment is the best choice for the new graduate nurse because a client whose discharge has been delayed due to a postoperative infection is likely stable and requires minimal immediate interventions. This client would benefit from the new nurse's routine care and monitoring skills, allowing the nurse to focus on completing tasks efficiently. Option B: With poorly controlled type 2 diabetes who is on a sliding scale for insulin administration requires close monitoring and frequent adjustments in insulin dosages, which may be challenging for a new nurse without adequate supervision. Option C: Newly admitted with a head injury who requires frequent assessments demands critical thinking skills and quick decision-making abilities, which may overwhelm a new nurse who lacks experience in handling such cases. Option D: Receiving IV heparin that is regulated based on protocol involves complex medication management and monitoring for potential complications, which may be beyond the scope of a new nurse's comfort level without proper guidance.

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