Nokea
The charge nurse is making assignments on an oncology floor. Which client should be assigned to the most experienced nurse?
- A. The client diagnosed with leukemia who has a hemoglobin of 6 g/dL.
- B. The client diagnosed with lung cancer with a pulse oximeter reading of 89%.
- C. The client diagnosed with colon cancer who needs the colostomy irrigated.
- D. The client diagnosed with Kaposi's sarcoma who is yelling at the staff.
Correct Answer: A
Rationale: Hemoglobin of 6 g/dL indicates severe anemia, requiring complex monitoring and transfusion, best handled by an experienced nurse. Hypoxia, colostomy care, or behavior are less acute.
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The wife of a client receiving hospice care being cared for at home calls the nurse to report the client is restless and agitated. Which interventions should the nurse implement? List in order of priority.
- A. Request an order from the health-care provider for antianxiety medications.
- B. Call the medical equipment company and request oxygen for the client.
- C. Go to the home and assess the client and address the wife's concerns.
- D. Reassure and calm the wife over the telephone.
- E. Notify the chaplain about the client's change in status.
Correct Answer: C,D,A,B,E
Rationale: 1) Assess client at home (determine cause of agitation); 2) Reassure wife (immediate support); 3) Request antianxiety medication (if indicated); 4) Request oxygen (if hypoxia present); 5) Notify chaplain (spiritual support).
The male client asks the nurse, 'Should I designate my wife as durable power of attorney for health care?' Which statement would be the nurse's best response?
- A. Yes, she should be because she is your next of kin.
- B. Most people don't allow their spouse to do this.
- C. Will your wife be able to support your wishes?
- D. Your children are probably the best ones for the job.
Correct Answer: C
Rationale: Choosing a proxy involves ensuring they’ll honor the client’s wishes, a key consideration. Kinship, rarity, or children are less relevant without this focus.
The nurse pronounced Dr. Smith's client to be clinically dead. Which should the nurse document on the client's chart?
- A. Brain scan indicates no brain wave activity, client pronounced deceased. Family refuses to talk with organ bank.
- B. Cardiac arrest noted, CPR initiated but unsuccessful. Pronounced dead.
- C. Pulse, respirations, and blood pressure absent at 0900, pronounced dead. Dr. Smith to sign death certificate.
- D. Client found without pulse, body cold to touch. Pronounced deceased at 0900.
Correct Answer: C
Rationale: Documentation should include objective findings (absent vital signs), time, and physician’s role, per legal standards. Brain scan or CPR details are specific, and cold body is insufficient.
The intensive care nurse is caring for a deceased client who is an organ donor, and the organ donation team is en route to the hospital. Which statement would be an appropriate goal of treatment for the client?
- A. The urinary output is 20 mL/hr via a Foley catheter.
- B. The systolic blood pressure is greater than 90 mm Hg.
- C. The pulse oximeter reading remains between 88% and 90%.
- D. The telemetry shows the client in sinus tachycardia.
Correct Answer: B
Rationale: Maintaining systolic BP >90 mm Hg ensures organ perfusion, a key goal for donation. Urine output, oximetry, or tachycardia are less critical post-death.
The HCP has notified the family of a client in a persistent vegetative state on a ventilator of the need to 'pull the plug.' The client does not have an AD or a durable power of attorney for health care, and the family does not want their loved one removed from the ventilator. Which action should the nurse implement?
- A. Refer the case to the hospital ethics committee.
- B. Tell the family they must do what the HCP orders.
- C. Follow the HCP's order and 'pull the plug.'
- D. Determine why the client did not complete an AD.
Correct Answer: A
Rationale: Without an AD or proxy, disagreements between family and HCP require ethics committee review for resolution. Forcing compliance, following orders against family wishes, or investigating AD absence is inappropriate.