Nokea
The client is in the psychiatric unit in a medical center. Which action by the psychiatric nurse is a violation of the client's legal and civil rights?
- A. The nurse tells the client civilian clothes can be worn on the unit.
- B. The nurse allows the client to have family visits during visiting hours.
- C. The nurse delivers unopened mail and packages to the client.
- D. The nurse listens to the client talking on the telephone to a friend.
Correct Answer: D
Rationale: Eavesdropping on a client’s phone call violates privacy rights, per civil liberties. Allowing clothes, visits, or mail respects client autonomy.
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The nurse is presenting an in-service discussing do not resuscitate (DNR) orders and advance directives. Which statement should the nurse discuss with the class?
- A. Advance directives must be notarized by a notary public.
- B. The client must use an attorney to complete the advanced directive.
- C. Once the DNR is written, it can be used for every hospital admission.
- D. The health-care provider must write the DNR order in the client's chart.
Correct Answer: D
Rationale: A DNR order requires a physician's written order in the chart to be actionable, per hospital policy. Notarization and attorneys are not required, and DNRs are typically re-evaluated per admission.
The client received a liver transplant and is preparing for discharge. Which discharge instruction should the nurse teach?
- A. The immune-suppressant drugs must be tapered off when discontinuing them.
- B. There may be slight foul-smelling drainage on the dressing for a few days.
- C. Notify the HCP immediately if a cough or fever develops.
- D. The skin will turn yellow from the antirejection drugs.
Correct Answer: C
Rationale: Cough or fever may indicate infection, critical post-transplant due to immunosuppression. Tapering drugs, foul drainage, or jaundice are incorrect or misleading.
The intensive care nurse is caring for a deceased client who is an organ donor, and the organ donation team is en route to the hospital. Which statement would be an appropriate goal of treatment for the client?
- A. The urinary output is 20 mL/hr via a Foley catheter.
- B. The systolic blood pressure is greater than 90 mm Hg.
- C. The pulse oximeter reading remains between 88% and 90%.
- D. The telemetry shows the client in sinus tachycardia.
Correct Answer: B
Rationale: Maintaining systolic BP >90 mm Hg ensures organ perfusion, a key goal for donation. Urine output, oximetry, or tachycardia are less critical post-death.
The client who is of the Jewish faith died during the night. The nurse notified the family, who do not want to come to the hospital. Which intervention should the nurse implement to address the family's behavior?
- A. Take no further action because this is an accepted cultural practice.
- B. Notify the hospital supervisor and report the situation immediately.
- C. Call the local synagogue and request the rabbi go to the family's home.
- D. Assume the family does not care about the client and follow hospital protocol.
Correct Answer: A
Rationale: In Jewish tradition, some families avoid hospital visits post-death, delegating care to professionals, a cultural norm. Supervisor reports, rabbi involvement, or assumptions are inappropriate.
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.