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The client has just signed an AD at the bedside. Which intervention should the nurse implement first?
- A. Notify the client's health-care provider about the AD.
- B. Instruct the client to discuss the AD with significant others.
- C. Place a copy of the advance directive in the client's chart.
- D. Give the original advance directive to the client.
Correct Answer: C
Rationale: Placing a copy in the chart ensures the AD is accessible for care decisions, the first priority. Notifying HCP, discussing with others, or giving the original follows.
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Which client would the nurse exclude from being a potential organ/tissue donor?
- A. The 60-year-old female client with an inoperable primary brain tumor.
- B. The 45-year-old female client with a subarachnoid hemorrhage.
- C. The 22-year-old male client who has been in a motor-vehicle accident.
- D. The 36-year-male client recently released from prison.
Correct Answer: A
Rationale: Primary brain tumors contraindicate organ donation due to malignancy risk, per UNOS guidelines. Hemorrhage, trauma, or prison status do not exclude donation.
The client has received a kidney transplant. Which assessment would warrant immediate intervention by the nurse?
- A. Fever and decreased urine output.
- B. Decreased creatinine and BUN levels.
- C. Decreased serum potassium and calcium.
- D. Bradycardia and hypotension.
Correct Answer: A
Rationale: Fever and decreased urine output suggest infection or rejection, requiring immediate action post-transplant. Decreased labs are expected, and vital signs are less specific.
The spouse of a client dying from lung cancer states, 'I don't understand this death rattle. She has not had anything to drink in days. Where is the fluid coming from?' Which is the hospice care nurse's best response?
- A. The body produces about two (2) teaspoons of fluid every minute on its own.
- B. Are you sure someone is not putting ice chips in her mouth?
- C. There is no reason for this, but it does happen from time to time.
- D. I can administer a patch to her skin to dry up the secretions if you wish.
Correct Answer: C
Rationale: The death rattle results from accumulated secretions in the throat, a normal end-of-life phenomenon, not fluid intake. Teaspoon estimates, ice chips, or patches are inaccurate or premature.
The client has been in a persistent vegetative state for several years. The family, who have decided to withhold tube feedings because there is no hope of recovery, asks the nurse, 'Will the death be painful?' Which intervention should the nurse implement?
- A. Tell the family the death will be painful but the HCP can order medications.
- B. Inform the family dehydration provides a type of natural euphoria.
- C. Relate other cases where the clients have died in excruciating pain.
- D. Ask the family why they are concerned because they want the client to die anyway.
Correct Answer: B
Rationale: Dehydration in end-of-life care often leads to a natural euphoria, reducing pain perception, per hospice evidence. Painful death, case comparisons, or questioning motives is unhelpful.
The nurse is assessing a client diagnosed with chronic pain. Which characteristics would the nurse observe?
- A. The client's blood pressure is elevated.
- B. The client has rapid shallow respirations.
- C. The client has facial grimacing.
- D. The client is lying quietly in bed.
Correct Answer: C
Rationale: Chronic pain may not cause vital sign changes but often manifests as facial grimacing, per pain assessment guidelines. Lying quietly can occur but isn’t diagnostic.