Nokea
A client with massive chest and head injuries is admitted to the ICU from the Emergency Department. All of the following are true except:
- A. the physician in charge of the case is the only person allowed to decide whether organ donation can occur.
- B. the client's legally responsible party may make the decision for organ donation for the donor if the client is unable to do so.
- C. the organ procurement organization makes the decision regarding which organs to harvest.
Correct Answer: C
Rationale: The client's legally responsible party may make the decision for organ donation if the client is unable to do so. The donor (or legally responsible party for the donor), the physician, and the organ-procurement organization are all involved in the process regarding whether organ donation is appropriate for a specific donor.
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The intent of the Patient Self Determination Act (PSDA) of 1990 is to:
- A. enhance personal control over legal care decisions
- B. encourage medical treatment decision making prior to need
- C. give one federal standard for living wills and durable powers of attorney
- D. emphasize client education
Correct Answer: B
Rationale: The PSDA encourages advance directives to promote proactive medical decision-making, ensuring clients' wishes are honored before a crisis.
Perineal care to a female client by the nurse can be performed:
- A. Without gloves, pouring water from a sterile bottle
- B. Without gloves, having the client perform all care
- C. With gloves, washing the perineal area from front to back
- D. With gloves, washing the perineal area from back to front
Correct Answer: C
Rationale: Perineal care requires gloves and washing from front to back to prevent bacterial contamination of the urethra, ensuring infection control.
The LPN is assisting the client with an NG tube with activities of daily living. Which of these statements would indicate need for teaching reinforcement?
- A. Since I'm not eating or drinking by mouth, I do not need to brush my teeth as often.
- B. I should remain sitting up at a 45-degree angle or higher for 30 minutes after a feeding.
- C. I can clean around the tube with water and mild soap.
- D. I should avoid using Vaseline around the nostril and tube.
Correct Answer: A
Rationale: Even when an NG tube is in place, the client still should brush his or her teeth twice daily. Good oral hygiene reduces the risk of introducing bacteria that may cause an infection.
Which of the following is an appropriate nursing goal for a client at risk for nutritional problems?
- A. provide oxygen
- B. promote healthy nutritional practices
- C. treat complications of malnutrition
- D. increase weight
Correct Answer: B
Rationale: Promoting healthy nutritional practices is an appropriate nursing goal for a client at risk for nutritional problems. Choice A is incorrect because it is a nursing intervention, not a goal statement. Choice C is incorrect because it is a therapeutic treatment. Choice D is incorrect because weight gain is an appropriate goal only if the client is underweight.
When making an occupied bed, it is important for the nurse to:
- A. keep the bed in the low position.
- B. use a bath blanket or top sheet for warmth and privacy.
- C. constantly keep side rails raised on both sides.
- D. move back and forth from one side to the other when adjusting the linens.
Correct Answer: B
Rationale: Using a bath blanket or top sheet keeps the client warm and provides privacy. Keeping the bed in the low position and working above raised side rails might strain the nurse's back. Continually moving back and forth to tuck and arrange linen is time-consuming and disorganized.