The triage nurse receives a call from a client with a history of type 2 diabetes mellitus controlled by metformin. The client is reporting muscle pain and shortness of breath with exercise. Which of the following is the most appropriate response from the nurse? a. Breathe into a paper bag to control hyperventilation b. Take ibuprofen 600 mg every 4-6 hours for the muscle pain c. See the client's primary health care provider today CorrectThe client needs to see a health care provider for further care. Lactic acidosis can occur when taking Metformin in the presence of dehydration and renal insufficiency, typically seen in type 2 diabetics. Manifestations of lactic acidosis include Kussmaul's breathing and severe muscle pain caused by the buildup of lactic acid in the muscles. d. Increase the amount of fluids to treat possible dehydration A nurse is preparing a client who speaks limited English for surgery. Which of the following is the most appropriate nursing action in obtaining informed consent from this client? a. The nurse should explain the procedures using pictures and hand gestures. b. Seek the assistance of a nurse on the floor who is fluent in the client's language. CorrectThe nurse is responsible for ensuring that the client understands the information provided regarding the procedure. c. Do nothing as this is the provider's primary concern. d. Have the nurse respond to the client's concerns so the provider can prepare for surgery. A nurse is performing initial teaching with a client who will be receiving electroconvulsive therapy (ECT). Which statement by the client indicates a need for further teaching? a. "Before the procedure, I will have an EKG to assess for heart irregularities." b. "I will stop taking my lithium for 2 weeks prior to my procedure." c. "I will need to continue taking my regular blood pressure medication." d. "My Dilantin dose will be increased several days before the procedure." CorrectBecause the therapeutic action of ECT is to induce seizures, any medications that affect the client's seizure threshold must be decreased or discontinued several days before the procedure. A daughter of a client with a terminal illness pulls a nurse to the side and says, "Although my mother's living will states she is not to be resuscitated, the family wants everything done to save her if she has a cardiac arrest." How should the nurse respond? a. "I will contact the provider to make him aware of your request." b. "The living will documents your mother's wishes and must be followed." CorrectA living will is a document that expresses the client's wishes regarding medical treatment in the event the client becomes incapacitated and is facing endof-life issues. The client's wishes should be followed by the health care provider. c. "Since the living will is a legal document a lawyer will have to make the changes." d. "If your mother has a cardiac arrest, we will begin resuscitation if you wish." A provider informs the wife of a comatose client with terminal cancer that she will need to sign the consent for insertion of a gastrostomy feeding tube. The nurse knows this is against the client's wishes. What is the appropriate action by the nurse? a. Consult the hospital's ethics committee. CorrectIf the nurse believes the provider's actions are directly against the client's wishes, the nurse should contact the hospital's ethics committee. These committees are typically multidisciplinary and are organized to consciously and reflectively consider significant and often difficult issues related to client care. Any nurse can consult the hospital's ethics committee when deemed necessary. b. Prepare the consent for the wife to sign. c. Inform the wife she cannot sign the consent d. Ask the provider for an order for a NG tube instead. A client is seeking treatment for stress related to unexpected loss of employment and is engaging in the stress management technique of cognitive reframing. Which of the following statements would indicate to the nurse that the client understands this stress management technique? a. "Once I decided what was most important to me, things got easier." b. "I can visualize the perfect interview and being offered a new job." c. "I have excellent job skills; I just need to find a new employer." CorrectCognitive reframing is a simple and effective technique for reducing stress by looking at things in a more positive light in order to experience them as less stressful. Cognitive reframing for this client would involve building confidence in job skills and searching for a new job. d. "When I do my daily yoga exercises, I feel so much better."