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The client is dying and wants to talk to the nurse about heaven. Which is the nurse's best nursing action?
- A. Make a referral to the chaplain to come to see the client.
- B. Tell the client that nurses are not allowed to discuss spiritual matters.
- C. Ask the client to describe heaven and hell.
- D. Allow the client to discuss the beliefs about heaven.
Correct Answer: D
Rationale: Allowing discussion of heaven respects client spirituality, per holistic care. Chaplain referral, prohibiting discussion, or prompting hell discussion is less supportive.
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The client is three (3) hours post-heart transplantation. Which data would support a complication of this procedure?
- A. The client has nausea after taking the oral antirejection medication.
- B. The client has difficulty coming off the heart-lung bypass machine.
- C. The client has saturated three (3) ABD dressing pads in one (1) hour.
- D. The client complains of pain at a '6' on a 1-to-10 scale.
Correct Answer: C
Rationale: Excessive bleeding (saturated dressings) indicates a surgical complication, requiring urgent intervention. Nausea, bypass difficulty, or moderate pain are less immediate.
Which client would be most likely to complete an advance directive?
- A. A 55-year-old Caucasian person who is a bank president.
- B. A 34-year-old Asian licensed practical nurse.
- C. A 22-year-old Hispanic lawn care worker.
- D. A 65-year-old African American retired cook.
Correct Answer: D
Rationale: Older adults (e.g., 65-year-old) are more likely to complete ADs due to increased awareness of mortality and health issues, regardless of ethnicity or profession.
Which act protects the nurse against a malpractice claim when the nurse stops at a motor-vehicle accident and renders emergency care?
- A. The Health Insurance Portability and Accountability Act.
- B. The State Nurse Practice Act.
- C. The Emergency Rendering Aid Act.
- D. The Good Samaritan Act.
Correct Answer: D
Rationale: The Good Samaritan Act protects nurses providing emergency care voluntarily, limiting malpractice liability. HIPAA, Nurse Practice Act, or fictional acts don’t apply.
The nurse is caring for a dying client and the family. The male client is Muslim. Which intervention should the nurse implement at the time of death?
- A. Allow the wife to stay in the room during postmortem care.
- B. Call the client's imam to perform last rites when the client dies.
- C. Place incense around the bed, but do not allow anyone to light it.
- D. Do not touch the body, and have the male family members perform care.
Correct Answer: D
Rationale: In Muslim tradition, family (often male) may perform postmortem care, respecting cultural practices. Wife’s presence, imam’s role, or incense are less specific.
The client had a mastectomy and lymph node dissection three (3) years ago and has experienced postmastectomy pain (PMP) since. Which intervention should the nurse implement?
- A. Have the client see a psychologist because the pain is not real.
- B. Tell the client the pain is the cancer coming back.
- C. Refer the client to a physical therapist to prevent a frozen shoulder.
- D. Discuss changing the client to a more potent narcotic medication.
Correct Answer: C
Rationale: PMP can lead to shoulder immobility; physical therapy prevents frozen shoulder, per evidence-based practice. Psychological dismissal, cancer assumptions, or narcotics are inappropriate.