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The client tells the nurse, 'Every time I come in the hospital you hand me one of these advance directives (AD). Why should I fill one of these out?' Which statement by the nurse is most appropriate?
- A. You must fill out this form because Medicare laws require it.
- B. An AD lets you participate in decisions about your health care.
- C. This paper will ensure no one can override your decisions.
- D. It is part of the hospital admission packet and I have to give it to you.
Correct Answer: B
Rationale: Advance directives allow clients to specify their health care preferences, ensuring participation in decisions, per the Patient Self-Determination Act. Medicare requires offering, not completing, ADs; no document guarantees non-override; and packet inclusion is procedural, not the reason.
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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 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 caring for a client who received a kidney transplant from an unrelated cadaver donor. Which interventions should be included in the plan of care? Select all that apply.
- A. Collect a urine culture every other day.
- B. Prepare the client for dialysis three (3) times a week.
- C. Monitor urine osmolality studies.
- D. Monitor intake and output every shift.
- E. Check abdominal dressing every four (4) hours.
Correct Answer: C,D,E
Rationale: Monitoring urine osmolality, intake/output, and dressings detects rejection or complications post-kidney transplant. Routine urine cultures or dialysis are unnecessary unless indicated.
The hospice care nurse is conducting a spiritual care assessment. Which statement is the scientific rationale for this intervention?
- A. The client will ask all of his or her spiritual questions and get answers.
- B. The nurse is able to explain to the client how death will affect the spirit.
- C. Spirituality provides a sense of meaning and purpose for many clients.
- D. The nurse is the expert when assisting the client with spiritual matters.
Correct Answer: C
Rationale: Spirituality offers meaning and purpose, supporting holistic hospice care. Clients may not ask all questions, nurses aren’t spiritual experts, and death’s spiritual impact is subjective.
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.