a 54 year old male client and his wife were informed this morning that he has terminal cancer which nursing intervention is likely to be most benefici
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Nursing Elites

HESI RN

HESI Fundamentals Quizlet

1. A 54-year-old male client and his wife were informed this morning that he has terminal cancer. Which nursing intervention is likely to be most beneficial?

Correct answer: A

Rationale: During this challenging time of dealing with a terminal cancer diagnosis, involving the wife in the care process can be highly beneficial. By asking the wife how she would like to participate in the client’s care, it allows her to feel more in control and connected. This approach fosters a collaborative care environment, ensuring that the wife's preferences and needs are taken into consideration. Providing information about hospice (choice B) may be premature at this stage and could potentially overwhelm the family. Encouraging the wife to visit during and after painful treatments (choice C) may not address her need for involvement in decision-making. Referring the wife to a support group (choice D) is helpful but may not directly involve her in the care process of her husband.

2. The healthcare professional is administering an intermittent infusion of an antibiotic to a client with an antecubital saline lock. After opening the roller clamp on the IV tubing, the alarm on the infusion pump indicates an obstruction. What action should be taken first?

Correct answer: B

Rationale: Repositioning the client's arm is the initial action to take when encountering an obstruction with an antecubital saline lock. Repositioning may correct any bending at the elbow that could be causing the obstruction, allowing for smoother infusion flow. Checking for a blood return, removing the IV site dressing, or flushing the lock with saline would be subsequent actions once the obstruction is addressed. Checking for a blood return is done to confirm proper placement, removing the IV site dressing is necessary for site assessment, and flushing the lock with saline helps maintain patency but should not be the first action when an obstruction is detected.

3. A client has a nursing diagnosis of 'spiritual distress.' What intervention is best for the nurse to implement when caring for this client?

Correct answer: D

Rationale: When a client is going through spiritual distress, employing reflective listening techniques is crucial. This method allows the client to voice their concerns and emotions, providing them with a supportive environment to explore their feelings. Options A and B do not directly address the client's spiritual distress and may undermine the client's feelings. While option C involves a chaplain, using reflective listening directly involves the nurse in addressing and supporting the client's spiritual concerns.

4. A healthcare professional stops at a motor vehicle collision site to render aid until the emergency personnel arrive and applies pressure to a groin wound that is bleeding profusely. Later, the client has to have the leg amputated and sues the healthcare professional for malpractice. What is the most likely outcome of this lawsuit?

Correct answer: C

Rationale: The Good Samaritan Act protects healthcare professionals who provide care in good faith and offer reasonable assistance in emergencies. This law shields them from malpractice claims, even if the outcome for the client is unfavorable. In this scenario, the healthcare professional is likely to be protected from judgment under the Good Samaritan Act. Choice A is incorrect because the situation does not involve the Patient's Bill of Rights, but rather the Good Samaritan Act. Choice B is incorrect as the license revocation is not a typical outcome in Good Samaritan cases. Choice D is incorrect as the Good Samaritan Act provides immunity from liability in such emergency situations.

5. The nurse is providing discharge teaching to a client with a new prescription for warfarin (Coumadin). Which dietary instruction should the nurse include?

Correct answer: A

Rationale: The correct dietary instruction for a client taking warfarin is to avoid foods high in vitamin K. Warfarin is an anticoagulant that works by inhibiting vitamin K-dependent clotting factors. Consuming foods high in vitamin K, such as leafy green vegetables, can antagonize the effects of warfarin, potentially leading to treatment inefficacy or fluctuations in anticoagulation levels. Therefore, clients on warfarin therapy should be advised to avoid foods high in vitamin K to maintain the effectiveness of the medication. Choices B, C, and D are incorrect because increasing leafy green vegetables (choice B) would introduce more vitamin K, consuming a consistent amount of foods high in potassium (choice C) is not directly related to warfarin therapy, and limiting high-protein foods (choice D) is not a specific concern for clients on warfarin therapy.

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