Nokea
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.
You may also like to solve these questions
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.
The nurse is teaching an in-service on legal issues in nursing. Which situation is an example of battery, an intentional tort?
- A. The nurse threatens the client who is refusing to take a hypnotic medication.
- B. The nurse forcibly inserts a Foley catheter in a client who refused it.
- C. The nurse tells the client a nasogastric tube insertion is not painful.
- D. The nurse gives confidential information over the telephone.
Correct Answer: B
Rationale: Battery involves nonconsensual physical contact, like forcible catheter insertion. Threats (assault), misrepresentation (negligence), or confidentiality breaches are not battery.
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 nurse is caring for the client who has active tuberculosis of the lungs. The client does not have a DNR order. The client experiences a cardiac arrest, and there is no resuscitation mask at the bedside. The nurse waits for the crash cart before beginning resuscitation. According to the ANA Code of Ethics for Nurses, which disciplinary action should be taken against the nurse?
- A. Report the action to the State Board of Nurse Examiners.
- B. The nurse should be terminated for failure to perform duties.
- C. No disciplinary action should be taken against the nurse.
- D. Refer the nurse to the American Nurses Association.
Correct Answer: C
Rationale: Waiting for a mask during TB resuscitation prioritizes nurse safety, aligning with ANA Code ethics (self-protection). Reporting, termination, or ANA referral is unwarranted.
The hospice nurse is admitting a client. Which question concerning end-of-life care is most important for the nurse to discuss with the client and family?
- A. Encourage the client and family to make funeral arrangements.
- B. Assess the client's pain medication regimen for effectiveness.
- C. Determine if the client has made an advance directive or living will.
- D. Ask what durable medical equipment is in place in the home.
Correct Answer: C
Rationale: Determining AD or living will status guides end-of-life care decisions, a hospice priority. Funeral plans, pain regimens, or equipment are secondary.