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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?
- A. Ensure transfer of the client's electronic chart code.
- B. Give a detailed report to accepting nurse.
- C. Give client written information about end-of-life care.
- D. Take the family to the client's new room.
Correct Answer: B
Rationale: A detailed report ensures continuity of care, critical for the client's palliative needs.
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A fire is reported in the kitchen on the first floor of a three-floor community hospital, and the operator notifies the charge nurse on the third floor to start evacuation procedures. Which intervention should the charge nurse implement?
- A. Instruct the nursing staff to evacuate ambulatory clients to the nearest fire exits.
- B. Instruct unlicensed assistive personnel (UAPs) to transfer all non-ambulatory clients via wheelchairs.
- C. Announce in a calm voice that all visitors should proceed immediately to the first floor via the service elevators.
- D. Shut all doors to client rooms and tell everyone to stay in their rooms until the fire department arrives.
Correct Answer: A
Rationale: Evacuating ambulatory clients to fire exits prioritizes their safety, following standard fire evacuation protocols.
The charge nurse, working with one nurse, two practical nurses (PNs), a unit secretary, and two unlicensed assistive personnel (UAPs), is caring for 24 clients on a medical surgical unit. Which task is best for the charge nurse to assign to the PN?
- A. Transcription of the healthcare provider's treatment plan for a client transferred from a critical care unit.
- B. The subclavian dressing change on a client diagnosed with inflammatory bowel disease.
- C. The admission assessment of a client diagnosed with bacterial pneumonia.
- D. The insertion of a Foley catheter for a client diagnosed with septicemia.
Correct Answer: D
Rationale: Foley catheter insertion is within the PN's scope, a task-based procedure suitable for their training.
The home health aide caring for a homebound hospice client calls to inform the nurse that the client has reported feeling constipated. Which task should the nurse instruct the home health aide to perform?
- A. Listen for the presence of bowel sounds.
- B. Administer a prescribed dose of a laxative.
- C. Teach the client about foods high in fiber.
- D. Assist the client to drink warm prune juice.
Correct Answer: D
Rationale: Assisting with warm prune juice is a safe, simple task within the aide's scope to relieve constipation.
The practical nurse (PN) is visiting a client who has stage four colon cancer and is receiving palliative home care. The client refuses to eat and sleeps most of the day. Which intervention should the nurse ask the PN to ensure the family is providing the client?
- A. Maintain in high Fowler's position.
- B. Report any change in urine color.
- C. Keep mucous membranes moist.
- D. Record the client's daily weight.
Correct Answer: C
Rationale: Keeping mucous membranes moist prevents discomfort and complications, a priority in palliative care.
An unlicensed assistive personnel (UAP) who is working on a skilled nursing unit is diagnosed with hepatitis A (HVA). Two weeks later, a nurse complains of headache, nausea, anorexia, arthralgia, and low-grade fever. Which action should the nurse-manager take next?
- A. Observe the nurse for jaundice and icterus sclera.
- B. Review the immunization status of all unit employees.
- C. Refer the nurse to employee health for serological testing.
- D. Post an employee notice of the outbreak of HVA on the unit.
Correct Answer: C
Rationale: Serological testing confirms HVA, enabling prompt diagnosis and treatment.