Nokea
A client has just been diagnosed with a terminal illness. She decides to execute a living will in the unit and asks the nurse to be the witness of the will. What is the most appropriate response by the nurse?
- A. I'm sorry, but under the law, we're not allowed to witness living wills.'
- B. Let me call the doctor. Maybe he can witness it for you.'
- C. Your family are the only people that can serve as witnesses.'
- D. Let me call the hospital attorney; he needs to be present when you sign your will.'
Correct Answer: A
Rationale: In many jurisdictions, nurses are restricted from witnessing living wills (A) due to potential conflicts of interest. Doctors (B) or attorneys (D) are not required, and family-only witnesses (C) is incorrect, as non-family can witness.
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The emergency department (ED) nurse is caring for a client who just arrived with a major thermal burn to 22.5% of the total body surface area (TBSA). Place the following actions in the order in which they need to be performed, starting from first to last.
- A. Establish a large bore peripheral vascular access device to unburned skin.
- B. Insert an indwelling urinary catheter to maintain urinary output 0.5 mL/kg/hr.
- C. Administer tetanus prophylaxis as prescribed.
- D. Administer supplemental oxygen if indicated and cover burns with sterile gauze.
- E. Assess the client's airway, breathing, and circulation and obtain vital signs.
- F. Administer prescribed isotonic fluids intravenously to maintain fluid balance.
Correct Answer: E, D, A, F, B, C
Rationale: Initial assessment of airway, breathing, circulation (E) ensures stability, followed by oxygen and burn coverage (D) for hypoxia prevention. IV access (A) and fluids (F) address shock, catheter insertion (B) monitors output, and tetanus prophylaxis (C) is last, as it’s preventive.
The emergency department (ED) nurse performs triage. Which client should the nurse prioritize care for? A client with
- A. hemophilia reporting knee and ankle stiffness with dizziness.
- B. chronic obstructive pulmonary disease (COPD) reporting a productive cough.
- C. chronic pericarditis reporting intermittent chest pain during inspiration.
- D. pain over the cheek radiating to the teeth, tenderness to percussion over the sinuses.
Correct Answer: A
Rationale: Hemophilia with joint stiffness and dizziness (A) suggests possible internal bleeding or anemia, a life-threatening emergency requiring immediate prioritization. COPD cough (B), pericarditis pain (C), and sinusitis (D) are less acute.
The nurse is discussing information about advanced directives with a client who expresses concerns, asking, 'What if I change my mind about what I want?' What approach would you use to respond to the client's care?
- A. Explain that the client would have to file a new witnessed document in order to make any changes.
- B. Discuss the need to be very sure about his preferences, as the living will is a binding legal document.
- C. Assure the client that he can change or revoke his advanced directives at any time.
- D. Advise the client that changes could not be made during this hospital stay.
Correct Answer: C
Rationale: Clients can change or revoke advance directives at any time (C), ensuring autonomy. New documents (A) may be needed but not restrictive, living wills are not unchangeable (B), and hospital stay (D) does not limit changes.
The nurse offers to stay late to assist the next shift because they are short-staffed. Which ethical principle is the nurse demonstrating?
- A. Non-maleficence
- B. Paternalism
- C. C. Beneficence
- D. D. Veracity
Correct Answer: C
Rationale: Staying late to assist (C) demonstrates beneficence by acting to benefit staff and clients through additional support. Non-maleficence (A), paternalism (B), and veracity (D) do not apply to this act of goodwill.
The nurse is caring for a 13-year-old in the pediatric unit with a left-side below-the-knee cast. The client reports pain and numbness in the foot. The nurse notes that the toes of the left foot are cold. Which of the following actions should the nurse take first?
- A. Remove the cast.
- B. Have the child ambulate.
- C. Notify the physician.
- D. Elevate the leg on two pillows.
Correct Answer: C
Rationale: Pain, numbness, and cold toes in a casted limb (C) suggest compartment syndrome, a medical emergency requiring immediate physician notification to prevent tissue damage. Removing the cast (A), ambulating (B), or elevating (D) without orders could worsen the condition.