Nokea
A nurse is caring for a client who asks for information regarding organ donation. Which of the following responses should the nurse make?
- A. I cannot be a witness for your consent to donate.
- B. You must be at least 21 years of age to become an organ donor.
- C. Your desire to be an organ donor must be documented in writing.
- D. Your name cannot be removed once you are listed on the organ donor list.
Correct Answer: C
Rationale: The correct response is C: Your desire to be an organ donor must be documented in writing. This is the correct answer because in order for someone to become an organ donor, their wish to donate organs after death must be formally documented. This ensures that their wishes are legally binding and will be respected. It also helps healthcare providers and family members honor the individual's decision.
Other choices are incorrect because:
A: This response does not provide the necessary information about organ donation.
B: Age requirements for organ donation may vary by country or region, but it is not a universal rule.
D: Individuals can opt-out of being an organ donor at any time, so this statement is false.
E, F, G: No information given, so it is unclear if these choices are relevant to organ donation.
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A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. For which of the following therapeutic effects should the nurse monitor the client?
- A. Deep tendon reflexes 2+
- B. Pulse rate 100/min
- C. Urine output 20 mL/hr
- D. 1+ proteinuria via urine dipstick
Correct Answer: A
Rationale: The correct answer is A: Deep tendon reflexes 2+. Monitoring deep tendon reflexes is crucial when a client is receiving magnesium sulfate due to its potential to cause muscle weakness and CNS depression. The nurse should assess for hyperreflexia, which indicates magnesium toxicity. Choices B, C, and D are incorrect as they do not directly relate to the therapeutic effect of magnesium sulfate. Pulse rate and urine output may be affected by the medication but are not specific therapeutic effects to monitor for. Proteinuria can be a sign of kidney damage but is not a direct effect of magnesium sulfate therapy.
A nurse is providing an in-service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first?
- A. A client who is ambulatory and receiving oxygen
- B. A client who has a fracture and is in balance suspension traction
- C. A client who is bedridden and wears a hearing aid
- D. A client who uses a wheelchair and is confused
Correct Answer: A
Rationale: The correct answer is A: A client who is ambulatory and receiving oxygen should be evacuated first during a fire. This client has the highest risk due to the combination of mobility impairment and oxygen use, which increases the potential for rapid deterioration in a fire emergency. Oxygen supports combustion, making this client more vulnerable to fire-related injuries.
Choice B: A client with a fracture in balance suspension traction is stable and can wait for evacuation. Choice C: A bedridden client with a hearing aid can still hear evacuation instructions and wait for assistance. Choice D: A confused client in a wheelchair may require assistance but is not at immediate risk like the ambulatory client with oxygen.
A nurse is caring for a client who is immobilized. Which of the following interventions is appropriate to prevent contracture?
- A. Position a pillow under the client's knees.
- B. Place a towel roll under the client's neck.
- C. Align a trochanter wedge between the client's legs.
- D. Apply an orthotic to the client's foot.
Correct Answer: D
Rationale: The correct answer is D: Apply an orthotic to the client's foot. Contractures are a common complication in immobilized clients, where muscles and tendons shorten and tighten due to lack of movement. Applying an orthotic to the foot helps maintain proper alignment and prevents the foot from being in a fixed position, thus reducing the risk of contractures. Positioning a pillow under the client's knees (A) may help with comfort but does not directly prevent contractures. Placing a towel roll under the client's neck (B) is unrelated to preventing contractures in the lower extremities. Aligning a trochanter wedge between the client's legs (C) is more for hip alignment and may not directly prevent contractures in the foot.
A nurse is reinforcing teaching with a client who has insomnia. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should turn on the ceiling fan to block out unwanted noise.
- B. I will limit my daily nap to 45 minutes.
- C. I will drink a cup of green tea at bedtime to help me sleep.
- D. I should get out of bed if I cannot fall asleep within an hour of lying down.
Correct Answer: B
Rationale: Correct Answer: B
Rationale: Limiting naps to 45 minutes can help improve nighttime sleep in individuals with insomnia by reducing excessive daytime sleepiness and ensuring better sleep quality at night. Longer naps can disrupt the body's natural sleep-wake cycle and make it harder to fall asleep at night. This statement shows an understanding of the importance of sleep hygiene practices for managing insomnia.
Summary:
A: Turning on the ceiling fan may help create white noise, but it does not address the underlying issue of improving sleep quality.
C: Drinking green tea before bedtime can actually worsen insomnia due to its caffeine content.
D: Getting out of bed if unable to sleep within an hour can disrupt the sleep routine and make it harder to fall asleep.
Therefore, the correct choice is B as it directly addresses the management of insomnia by improving sleep habits.
A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?
- A. A client who has epidural analgesia and weakness in the lower extremities.
- B. A client who has a hip fracture and a new onset of tachypnea.
- C. A client who has sinus arrhythmia and is receiving cardiac monitoring.
- D. A client who has diabetes mellitus and an HbA1C of 6.8%.
Correct Answer: B
Rationale: The correct answer is B because a client with a hip fracture and new onset of tachypnea may have a pulmonary embolism, a life-threatening complication that requires immediate assessment and intervention. Tachypnea can indicate hypoxia, which can be fatal if not addressed promptly. The nurse should prioritize assessing this client to ensure timely management and prevent further deterioration.
Clients A, C, and D do not present with immediate life-threatening conditions that require urgent assessment compared to client B. Client A's weakness in the lower extremities, client C's sinus arrhythmia, and client D's HbA1C level do not pose immediate risks to their health. Therefore, the nurse should assess client B first to address the potential pulmonary embolism.