Nokea
The 38-year-old client was brought to the emergency department with CPR in progress and expired 15 minutes after arrival. Which intervention should the nurse implement for postmortem care?
- A. Do not allow significant others to see the body.
- B. Do not remove any tubes from the body.
- C. Prepare the body for the funeral home.
- D. Send the client's clothing to the hospital laundry.
Correct Answer: C
Rationale: Preparing the body (e.g., cleaning, positioning) respects dignity and funeral home needs. Denying family access, leaving tubes, or laundering clothes is inappropriate.
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The client who is of the Jewish faith died during the night. The nurse notified the family, who do not want to come to the hospital. Which intervention should the nurse implement to address the family's behavior?
- A. Take no further action because this is an accepted cultural practice.
- B. Notify the hospital supervisor and report the situation immediately.
- C. Call the local synagogue and request the rabbi go to the family's home.
- D. Assume the family does not care about the client and follow hospital protocol.
Correct Answer: A
Rationale: In Jewish tradition, some families avoid hospital visits post-death, delegating care to professionals, a cultural norm. Supervisor reports, rabbi involvement, or assumptions are inappropriate.
The client had a mastectomy and lymph node dissection three (3) years ago and has experienced postmastectomy pain (PMP) since. Which intervention should the nurse implement?
- A. Have the client see a psychologist because the pain is not real.
- B. Tell the client the pain is the cancer coming back.
- C. Refer the client to a physical therapist to prevent a frozen shoulder.
- D. Discuss changing the client to a more potent narcotic medication.
Correct Answer: C
Rationale: PMP can lead to shoulder immobility; physical therapy prevents frozen shoulder, per evidence-based practice. Psychological dismissal, cancer assumptions, or narcotics are inappropriate.
The 6-year-old client diagnosed with cystic fibrosis (CF) needs a lung transplant. Which individual would be the best donor for the client?
- A. The 20-year-old brother who does not have cystic fibrosis.
- B. The 45-year-old father who carries the cystic fibrosis gene.
- C. The 18-year-old who died in an MVA who matches on four (4) points.
- D. The 18-year-old drowning victim who is a three (3)-point match.
Correct Answer: A
Rationale: A healthy sibling (20-year-old brother) offers the best HLA match and living donor potential, minimizing rejection. Carrier status or partial matches are less optimal.
The nurse is caring for clients on a medical floor. Which client should the nurse assess first after the shift report?
- A. The client with arterial blood gases of pH 7.36, Paco2 40, HCO3 26, Pao2 90.
- B. The client with vital signs of T 99°F, P 101, R 28, and BP 120/80.
- C. The client complaining of pain at a '10' on a 1-to-10 scale who can't localize it.
- D. The client who is postappendectomy with pain at a '3' on a 1-to-10 scale.
Correct Answer: C
Rationale: Severe pain (10/10), especially nonlocalizable, may indicate a serious condition (e.g., ischemia), requiring immediate assessment. Normal ABGs, mild vital sign changes, or mild post-op pain are less urgent.
The nurse is discussing the HCP's recommendation for removal of life support with the client's family. Which information concerning brain death should the nurse teach the family?
- A. Positive waves on the electroencephalogram (EEG) mean the brain is dead and any further treatment is futile.
- B. When putting cold water in the ear, if the client reacts by pulling away, this demonstrates brain death.
- C. Tests will be done to determine if any brain activity exists before the machines are turned off.
- D. Although the blood flow studies don't indicate activity, the client can still come out of the coma.
Correct Answer: C
Rationale: Brain death requires tests (e.g., EEG, apnea test) to confirm no brain activity, per medical standards. Positive EEG waves, caloric reflex, or coma recovery are incorrect.