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A nurse is caring for a client who has a terminal illness. The client asks several
questions about the nurse's religious beliefs related to death and dying. Which of the
following actions should the nurse take?
A) Change the topic because the client is trying to divert attention from the illness to the
nurse.
B) Encourage the client to express his thoughts about death and dying?
C) Tell the client that religious beliefs are a personal matter.
D) Offer to contact the client's minister or the facility's chaplain.
B
A nurse should recognize the client's need to talk about impending death, and
encourage the client to discuss his thoughts on the subject. This is therapeutic
technique of reflecting. Depending on the situation, the nurse can also share some
thoughts on this topic. Self-disclosure is a communication skill that can help open lines
of communication when appropriate. If the nurse does not want to share personal
beliefs, the communication skills of offering self and listening to the client's thoughts are
appropriate.
A nurse is preparing to provide tracheostomy care for a client. Which of the following
actions should the nurse take first?
A) Open all sterile supplies and solutions.
B) Stabilize the tracheostomy tube.
C) Don sterile gloves.
D) Perform hand hygiene.
D
According to evidence-based practice, the nurse should first perform hand hygiene
before touching the client or performing any skills, such as tracheostomy care. This is
vital because contamination of the nurse's hands is a primary source of infection.
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A nurse is measuring vital signs for a client and notices an irregularity in the pulse.
Which of the following actions should the nurse take?
A) Measure the pulse using a Doppler ultrasound stethoscope.
B) Check the client's pedal pulses.
C) Count the apical pulse rate for a full minute and describe the rhythm in the chart.
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