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The nurse is obtaining the client’s signature on a surgical permit form. The nurse determines the client does not understand the surgical procedure and possible risks. Which action should the nurse take first?
- A. Notify the client's surgeon.
- B. Document the information in the chart.
- C. Contact the operating room staff.
- D. Explain the procedure to the client.
Correct Answer: A
Rationale: Notifying the surgeon ensures informed consent, as the surgeon must clarify risks and procedures. Documentation, OR contact, or nurse explanation is secondary.
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The nurse is giving an in-service on end-of-life issues. Which activity should the nurse encourage the participants to perform?
- A. Discuss with another participant the death of a client.
- B. Review the hospital postmortem care policy.
- C. Justify not putting the client in a shroud after dying.
- D. Write down their own beliefs about death and dying.
Correct Answer: D
Rationale: Writing personal beliefs fosters self-awareness, enhancing end-of-life care competence. Client death discussions, policy review, or shroud justification are less introspective.
Which intervention should the nurse implement to provide culturally sensitive health care to the European-American Caucasian elderly client who is terminal?
- A. Discuss health-care issues with the oldest male child.
- B. Determine if the client will be cremated or have an earth burial.
- C. Do not talk about death and dying in front of the client.
- D. Encourage the client's autonomy and answer questions truthfully.
Correct Answer: D
Rationale: Encouraging autonomy and honesty respects individual preferences, common in European-American culture, per patient-centered care. Family roles, burial plans, or avoiding death talk are less universal.
The client has received a kidney transplant. Which assessment would warrant immediate intervention by the nurse?
- A. Fever and decreased urine output.
- B. Decreased creatinine and BUN levels.
- C. Decreased serum potassium and calcium.
- D. Bradycardia and hypotension.
Correct Answer: A
Rationale: Fever and decreased urine output suggest infection or rejection, requiring immediate action post-transplant. Decreased labs are expected, and vital signs are less specific.
The nurse is caring for a client who received a kidney transplant from an unrelated cadaver donor. Which interventions should be included in the plan of care? Select all that apply.
- A. Collect a urine culture every other day.
- B. Prepare the client for dialysis three (3) times a week.
- C. Monitor urine osmolality studies.
- D. Monitor intake and output every shift.
- E. Check abdominal dressing every four (4) hours.
Correct Answer: C,D,E
Rationale: Monitoring urine osmolality, intake/output, and dressings detects rejection or complications post-kidney transplant. Routine urine cultures or dialysis are unnecessary unless indicated.
The client diagnosed with cancer is experiencing severe pain. Which regimen would the nurse teach the client about to control the pain?
- A. Nonsteroidal anti-inflammatory drugs (NSAIDs) around the clock with narcotics used for severe pain.
- B. Morphine sustained release, a narcotic, routinely with a liquid morphine preparation for breakthrough pain.
- C. Extra-Strength Tylenol, a nonnarcotic analgesic, plus therapy to learn alternative methods of pain control.
- D. Demerol, an opioid narcotic, every six (6) hours orally with a suppository when the pain is not controlled.
Correct Answer: B
Rationale: Sustained-release morphine with breakthrough doses is standard for cancer pain, per WHO pain ladder. NSAIDs, Tylenol, or Demerol regimens are less effective or outdated.