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The client diagnosed with septicemia expired, and the family tells the nurse the client is an organ donor. Which intervention should the nurse implement?
- A. Notify the organ and tissue organizations to make the retrieval.
- B. Explain a systemic infection prevents the client from being a donor.
- C. Call and notify the health-care provider of the family's request.
- D. Take the body to the morgue until the organ bank makes a decision.
Correct Answer: B
Rationale: Systemic infections like septicemia contraindicate organ donation due to infection risk, per UNOS guidelines. Notification, HCP calls, or morgue transfer are premature.
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The hospice nurse is making the final visit to the wife whose husband died a little more than a year ago. The nurse realizes the husband's clothes are still in the closet and chest of drawers. Which action should the nurse implement first?
- A. Discuss what the wife is going to do with the clothes.
- B. Refer the wife to a grief recovery support group.
- C. Do not take any action because this is normal grieving.
- D. Remove the clothes from the house and dispose of them.
Correct Answer: C
Rationale: Keeping clothes is a normal part of grieving, requiring no immediate action. Discussing plans, referring to support, or removing clothes may rush or distress the widow.
The nurse is aware the Patient Self-Determination Act of 1991 requires the health-care facility to implement which action?
- A. Make available an AD on admission to the facility.
- B. Assist the client with legally completing a will.
- C. Provide ethically and morally competent care to the client.
- D. Discuss the importance of understanding consent forms.
Correct Answer: A
Rationale: The Patient Self-Determination Act mandates offering AD information on admission for Medicare/Medicaid facilities. Wills, ethical care, and consent forms are unrelated.
Which tissue or organ can be repeatedly donated to clients needing a transplant?
- A. Skin.
- B. Bones.
- C. Kidneys.
- D. Bone marrow.
Correct Answer: D
Rationale: Bone marrow regenerates, allowing repeated donation. Skin, bones, and kidneys are limited or single-donation tissues/organs.
The client is on the ventilator and has been declared brain dead. The spouse refuses to allow the ventilator to be discontinued. Which collaborative action by the nurse is most appropriate?
- A. Discuss referral of the case to the ethics committee.
- B. Pull the plug when the spouse is not in the room.
- C. Ask the HCP to discuss the futile situation with the spouse.
- D. Inform the spouse what is happening is cruel.
Correct Answer: A
Rationale: Ethics committee referral addresses conflicts over futile care, respecting family wishes and legal standards. Unilateral action, HCP discussion, or calling it cruel is inappropriate.
The male client diagnosed with chronic pain since a construction accident which broke several vertebrae tells the nurse he has been referred to a pain clinic and asks, 'What good will it do? I will never be free of this pain.' Which statement is the nurse's best response?
- A. Are you afraid of the pain never going away?
- B. The pain clinic will give you medication to cure the pain.
- C. Pain clinics work to help you achieve relief from pain.
- D. I am not sure. You should discuss this with your HCP.
Correct Answer: C
Rationale: Pain clinics offer multimodal relief (e.g., therapy, medications), addressing chronic pain holistically. Fear exploration, cure promises, or deferring to HCP is less supportive.