Nokea
An adult woman with metastatic pancreatic cancer has requested that no heroic measures are implemented to save her life. Instructions from the healthcare provider have been received to transfer the client to a palliative care room. Which action is most important for the nurse to take first?
- A. Ensure transfer of the client's electronic chart code.
- B. Give a detailed report to the accepting nurse.
- C. Take the family to the client's new room.
- D. Give the client written information about end-of-life care.
Correct Answer: B
Rationale: Giving a detailed report ensures continuity of care, critical for the client's palliative needs. Transferring chart codes, escorting family, or providing written information are secondary to effective handoff.
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A newly hired unlicensed assistive personnel (UAP) expresses fear to the charge nurse about collecting a sputum specimen from a client who is HIV positive. Which action should the charge nurse take first?
- A. Demonstrate the proper use of personal protective equipment.
- B. Offer to assist the UAP with the collection of the specimen.
- C. Provide the UAP with the infection control policy.
- D. Determine the UAP's knowledge about HIV transmission.
Correct Answer: D
Rationale: Determining the UAP's knowledge about HIV transmission is the first step to address misconceptions and fears, enabling targeted education. Demonstrating PPE, assisting with collection, or providing policy are secondary actions that follow understanding the UAP's knowledge gaps.
Which staff assignment, made by the primary nurse, requires the most immediate follow-up action by the charge nurse on a medical unit?
- A. A practical nurse is assigned to transport a postoperative client to the rehabilitation unit.
- B. A practical nurse (PN) is assigned to monitor the blood pressure of a client with hypertension.
- C. A graduate nurse is assigned to obtain a unit of packed red blood cells from the blood bank.
- D. An unlicensed assistive personnel (UAP) is assigned to check a client for fecal impaction.
Correct Answer: D
Rationale: Checking for fecal impaction is beyond the UAP's scope, risking client injury. The other assignments (transport, BP monitoring, blood retrieval) are within the respective staff's competencies.
A 5-year-old boy with mumps is being transferred to the pediatric unit. Which nursing intervention is most important for the nurse to implement?
- A. Place an isolation cart outside of the room to initiate droplet precautions.
- B. Schedule bedside play time with the occupational therapist.
- C. Instruct the child's parents about the need for transmission precautions.
- D. Assign the child to a room close to the nurse's station.
Correct Answer: A
Rationale: Initiating droplet precautions with an isolation cart prevents mumps transmission, a priority for infection control. Play time, parent instruction, and room assignment are secondary.
A postoperative client's respiratory rate decreased from 14 breaths/minute to 6 breaths/minute after administration of an opioid analgesic. Thirty minutes later, the client's respiratory rate decreases to 4 breaths/minute, and the nurse caring for the client notifies the healthcare provider and administers a dose of intravenous (IV) naloxone. The charge nurse should counsel the nurse regarding which intervention?
- A. The initial administration of the analgesic.
- B. The decision regarding when to call the healthcare provider.
- C. The documentation of the client's respiratory rate.
- D. The administration of naloxone via IV.
Correct Answer: B
Rationale: The nurse should have notified the provider at a respiratory rate of 6 breaths/minute, as this indicates opioid-induced respiratory depression. Delaying until 4 breaths/minute risked client safety. Other interventions were appropriate.
After an interdisciplinary team meeting regarding the client's request to die a natural death, the primary healthcare provider refuses to write the do-not-resuscitate instructions. Which action should the nurse take?
- A. Facilitate a palliative care meeting with the client and healthcare provider.
- B. Remind the client that new treatments are being developed daily.
- C. Provide the healthcare provider with a copy of the client's bill of rights.
- D. Initiate a review of the situation by the hospital's ethics committee.
Correct Answer: D
Rationale: An ethics committee review mediates conflicts and protects client rights when the provider opposes the client's wishes. Palliative meetings, mentioning treatments, or providing rights are less effective in resolving the ethical dilemma.