Nokea
Which action by the unlicensed assistive personnel (UAP) would warrant immediate intervention by the nurse?
- A. The UAP is holding the phone to the ear of a client who is a quadriplegic.
- B. The UAP refuses to discuss the client's condition with the visitor in the room.
- C. The UAP put a vest restraint on an elderly client found wandering in the hall.
- D. The UAP is assisting the client with arthritis to open up personal mail.
Correct Answer: C
Rationale: Applying restraints without a physician’s order violates safety and legal standards, requiring intervention. Other actions are appropriate UAP tasks.
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The spouse of a client dying from lung cancer states, 'I don't understand this death rattle. She has not had anything to drink in days. Where is the fluid coming from?' Which is the hospice care nurse's best response?
- A. The body produces about two (2) teaspoons of fluid every minute on its own.
- B. Are you sure someone is not putting ice chips in her mouth?
- C. There is no reason for this, but it does happen from time to time.
- D. I can administer a patch to her skin to dry up the secretions if you wish.
Correct Answer: C
Rationale: The death rattle results from accumulated secretions in the throat, a normal end-of-life phenomenon, not fluid intake. Teaspoon estimates, ice chips, or patches are inaccurate or premature.
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 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 entity mandates the registered nurse's behavior when practicing professional nursing?
- A. The state's Nurse Practice Act.
- B. Client's Bill of Rights.
- C. The United States legislature.
- D. American Nurses Association.
Correct Answer: A
Rationale: The state’s Nurse Practice Act defines legal scope and behavior for nurses, enforceable by law. Other entities provide guidelines, not mandates.
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.