Nokea
The client has been declared brain dead and is an organ donor. The nurse is preparing the wife of the client to enter the room to say good-bye. Which information is most important for the nurse to discuss with the wife?
- A. Inform the wife the client will still be on the ventilator.
- B. Instruct the wife to only stay a few minutes at the bedside.
- C. Tell the wife it is all right to talk to the client.
- D. Allow another family member to go in with the wife.
Correct Answer: A
Rationale: Informing the wife about the ventilator prepares her for the client’s appearance, reducing distress, a priority for organ donors. Time limits, talking, or companions are secondary.
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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.
The client with chronic low back pain is having trouble sleeping at night. Which nonpharmacological therapy should the nurse teach the client?
- A. Acupuncture.
- B. Massage therapy.
- C. Herbal remedies.
- D. Progressive relaxation techniques.
Correct Answer: D
Rationale: Progressive relaxation reduces muscle tension and promotes sleep, a safe nonpharmacological option. Acupuncture, massage, or herbs are less directly linked to sleep.
The male client in the long-term care facility has been told that he will not live for many more months. The client has been estranged from his daughter for years. He tells the nurse that he could die a happy man if he could talk to his daughter just one more time. Which statement is the nurse's best response?
- A. You should not feel bad. Things will work out for the best before your death.
- B. What did you do to make your daughter not talk to you all this time?
- C. If you would like I can try to contact your daughter and ask her to come see you.
- D. Tell me more about being unhappy that you don't have a relationship with your daughter.
Correct Answer: C
Rationale: Offering to contact the daughter supports the client’s wish, per patient-centered care. Minimizing feelings, blaming, or exploring unhappiness is less actionable.
The pregnant client asks the nurse about banking the cord blood. Which information should the nurse teach the client?
- A. The procedure involves a lot of pain with a very poor result.
- B. The client must deliver at a large public hospital to do this.
- C. The client will be charged a yearly storage fee on the cells.
- D. The stem cells can be stored for about four (4) years before they ruin.
Correct Answer: C
Rationale: Cord blood banking involves annual storage fees for stem cells, per industry standards. Pain, hospital requirements, or four-year limits are inaccurate.
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.