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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 caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take?
- A. Discuss the risk factors for colon cancer.
- B. Focus teaching on what the client will need to do in the future to manage his illness.
- C. Provide the client with written information about the phases of loss and grief.
- D. Reassure the client that this is an expected response to grief.
Correct Answer: D
Rationale: The correct answer is D: Reassure the client that this is an expected response to grief. By reassuring the client that feeling anger about the diagnosis of colorectal cancer is a normal part of the grieving process, the nurse acknowledges the client's emotions and validates their experience. This can help the client feel understood and supported, fostering a therapeutic relationship. Discussing risk factors (A) may not address the client's current emotional needs. Teaching future management (B) may be premature as the client is currently expressing anger. Providing written information on loss and grief phases (C) may not directly address the client's anger. Therefore, the best immediate action is to validate the client's emotions and offer reassurance (D).
A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which of the following is an appropriate action for the nurse to take?
- A. Document the client's behavior prior to being placed in seclusion.
- B. Assess the client's behavior once every hour.
- C. Offer fluids every 2 hours.
- D. Discuss with the client his inappropriate behavior prior to seclusion.
Correct Answer: A
Rationale: The correct answer is A because documenting the client's behavior before seclusion is essential for comprehensive care, ensuring accurate assessment, and treatment planning. This documentation provides crucial information for evaluating the effectiveness of seclusion, understanding triggers, and creating a safer environment. Assessing the client's behavior, offering fluids, or discussing inappropriate behavior are important but secondary to documenting behavior for legal, ethical, and continuity of care reasons. Monitoring behavior continuously is more effective than hourly assessments.
A nurse is caring for a client who has acute glomerulonephritis. Which of the following findings should the nurse expect?
- A. Oliguria
- B. Hypotension
- C. Weight loss
- D. Hematuria
Correct Answer: D
Rationale: The correct answer is D: Hematuria. In acute glomerulonephritis, there is inflammation of the glomeruli in the kidneys, leading to blood in the urine. This is due to damage to the glomerular capillaries allowing red blood cells to leak into the urine. Oliguria (A) is not a common finding as there is usually normal to increased urine output. Hypotension (B) is not typically seen as glomerulonephritis can lead to fluid overload and hypertension. Weight loss (C) is unlikely as fluid retention is common. Hematuria (D) is the hallmark finding due to the damage to glomeruli.
A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution?
- A. Remove the cap and place it sterile-side up on a clean surface.
- B. Place sterile gauze over areas of spilled solution within the sterile field.
- C. Hold the bottle in the center of the sterile field when pouring the solution.
- D. Hold the irrigation solution bottle with the label facing away from the palm of the hand.
Correct Answer: A
Rationale: The correct answer is A: Remove the cap and place it sterile-side up on a clean surface. This is essential to maintain the sterility of the solution and prevent contamination. Placing the cap sterile-side up ensures that the inside of the cap, which will come in contact with the solution again, remains sterile. Placing it on a clean surface prevents contamination from the surface. Options B, C, and D do not directly address maintaining the sterility of the solution. Option B is about spill management within the sterile field, which is important but not the primary concern when pouring the solution. Holding the bottle in the center (Option C) or with the label facing away (Option D) does not directly impact the sterility of the solution.
A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies?
- A. Biofeedback
- B. Aloe
- C. Herbal remedies
- D. Acupuncture
Correct Answer: A
Rationale: The correct answer is A: Biofeedback. Biofeedback involves monitoring and controlling bodily functions to reduce pain and stress. In the case of herpes zoster, the skin lesions can be very sensitive, making it uncomfortable for the client to participate in biofeedback sessions. Additionally, the focus required for biofeedback may be challenging for someone experiencing pain from herpes zoster.
B: Aloe is a natural remedy that can be used topically to soothe skin irritations, including herpes zoster lesions. However, it may not provide adequate pain control.
C: Herbal remedies can be used to help manage pain in herpes zoster, such as capsaicin cream. While some herbal remedies may interact with medications, there is no general contraindication for their use in herpes zoster.
D: Acupuncture is a complementary therapy that involves inserting thin needles into specific points on the body to alleviate pain. It can be effective for pain relief in herpes zoster and is not contraindicated