Nokea
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.
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The 38-year-old client was brought to the emergency department with CPR in progress and expired 15 minutes after arrival. Which intervention should the nurse implement for postmortem care?
- A. Do not allow significant others to see the body.
- B. Do not remove any tubes from the body.
- C. Prepare the body for the funeral home.
- D. Send the client's clothing to the hospital laundry.
Correct Answer: C
Rationale: Preparing the body (e.g., cleaning, positioning) respects dignity and funeral home needs. Denying family access, leaving tubes, or laundering clothes is inappropriate.
The charge nurse is making assignments on an oncology floor. Which client should be assigned to the most experienced nurse?
- A. The client diagnosed with leukemia who has a hemoglobin of 6 g/dL.
- B. The client diagnosed with lung cancer with a pulse oximeter reading of 89%.
- C. The client diagnosed with colon cancer who needs the colostomy irrigated.
- D. The client diagnosed with Kaposi's sarcoma who is yelling at the staff.
Correct Answer: A
Rationale: Hemoglobin of 6 g/dL indicates severe anemia, requiring complex monitoring and transfusion, best handled by an experienced nurse. Hypoxia, colostomy care, or behavior are less acute.
The HCP has notified the family of a client in a persistent vegetative state on a ventilator of the need to 'pull the plug.' The client does not have an AD or a durable power of attorney for health care, and the family does not want their loved one removed from the ventilator. Which action should the nurse implement?
- A. Refer the case to the hospital ethics committee.
- B. Tell the family they must do what the HCP orders.
- C. Follow the HCP's order and 'pull the plug.'
- D. Determine why the client did not complete an AD.
Correct Answer: A
Rationale: Without an AD or proxy, disagreements between family and HCP require ethics committee review for resolution. Forcing compliance, following orders against family wishes, or investigating AD absence is inappropriate.
The client diagnosed with diabetes mellitus type 2 wants to be an organ donor and asks the nurse, 'Which organs can I donate?' Which statement is the nurse's best response?
- A. It is wonderful you want to be an organ donor. Let's discuss this.
- B. You can donate any organ in your body, except the pancreas.
- C. You have to donate your body to science to be an organ donor.
- D. You cannot donate any organs, but you can donate some tissues.
Correct Answer: D
Rationale: Type 2 diabetes may contraindicate organ donation (e.g., kidneys, pancreas) due to vascular damage, but tissues (e.g., corneas) are often viable. Other responses are inaccurate.
Which element is not necessary to prove nursing malpractice?
- A. Breach of duty.
- B. Identify the ethical issues.
- C. Injury to the client.
- D. Proximate cause.
Correct Answer: B
Rationale: Malpractice requires duty, breach, injury, and causation. Identifying ethical issues is not a legal element, though relevant to ethics.