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A hospice patient with end-stage renal disease refuses to eat or drink and is very weak but reports no pain. Which nursing action is most appropriate?
- A. Teach the family about the use of enteral feedings to improve nutrition.
- B. Discuss the benefits of inserting a feeding tube for hydration.
- C. Provide support for the patient’s decision and ensure comfort measures.
- D. Inform the patient about the risks of refusing food and fluids.
Correct Answer: C
Rationale: The most appropriate nursing action in this scenario is choice C: Provide support for the patient’s decision and ensure comfort measures. This is because the patient is in hospice care, indicating a focus on comfort and quality of life rather than aggressive treatments. By respecting the patient’s decision and providing comfort measures, the nurse promotes dignity and autonomy. Choices A and B are not suitable as they go against the patient's wishes and may cause distress. Choice D, while important, is not the immediate priority when the patient is not in pain and has chosen to refuse food and fluids. Overall, choice C aligns with the principles of hospice care and prioritizes the patient's comfort and autonomy.
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When planning the response to the potential use of smallpox as an agent of terrorism, the emergency department (ED) nurse manager will plan to obtain adequate quantities of:
- A. Vaccine.
- B. Atropine.
- C. Antibiotics.
- D. Whole blood.
Correct Answer: A
Rationale: The correct answer is A: Vaccine. Smallpox is a contagious and potentially deadly disease caused by the variola virus. The smallpox vaccine is the most effective way to prevent and control the spread of smallpox. By obtaining adequate quantities of the smallpox vaccine, the ED nurse manager can protect healthcare workers and the public from contracting the virus in case of a smallpox bioterrorism event. Atropine (B) is used to treat certain types of nerve agent poisoning, not smallpox. Antibiotics (C) are ineffective against viruses like smallpox. Whole blood (D) is not specifically needed for smallpox treatment.
The nurse is caring for a patient who has sustained blunt trauma to the left flank area, and is evaluating the patient’s urinalysis results. The nurse should become concerned when
- A. creatinine levels in the urine are similar to blood levels of creatinine.
- B. sodium and chloride are found in the urine.
- C. urine uric acid levels have the same values as serum levels.
- D. red blood cells and albumin are found in the urine.
Correct Answer: D
Rationale: The correct answer is D because the presence of red blood cells and albumin in the urine indicates possible kidney damage from the blunt trauma. This is concerning as it may suggest renal injury or dysfunction.
A: Creatinine levels in the urine being similar to blood levels is normal as creatinine is filtered by the kidneys.
B: Sodium and chloride being present in the urine is expected as they are components of urine.
C: Urine uric acid levels matching serum levels is common as uric acid is excreted by the kidneys.
In summary, the presence of red blood cells and albumin in the urine is abnormal and indicates potential kidney damage, making it the correct answer.
The nurse aware that a shortage of organs exists knows that which statement is true?
- A. Anyone who is comfortable approaching the family sh ould discuss the option of organ donation.
- B. Brain death determination is required before organs ca n be retrieved for transplant.
- C. Donation of selected organs after cardiac death is ethically acceptable.
- D. Family members should consider withdrawing life supapboirbrt.c osmo /ttehsat t the patient can become an organ donor.
Correct Answer: B
Rationale: Rationale for Correct Answer (B - Brain death determination is required before organs can be retrieved for transplant):
1. Brain death determination is a medical necessity to ensure the organs are viable for transplant.
2. Organs must be retrieved promptly after brain death to maintain their functionality.
3. Brain death criteria ensure that the donor is truly deceased before organ retrieval.
Summary of Why Other Choices are Incorrect:
A: While discussing organ donation is important, comfort level is not the main factor in organ shortage awareness.
C: Donation after cardiac death is ethically acceptable, but it is not directly related to the need for brain death determination.
D: Withdrawing life support solely to become an organ donor is ethically questionable and not a necessary step in organ donation.
A 16-year-old male client is admitted to the hospital after falling off a bike and sustaining a fractured bone. The healthcare provider explains the surgery needed to immobilize the fracture. Which action should be implemented to obtain a valid informed consent?
- A. Obtain the permission of the custodial parent for the surgery.
- B. Notify the non-custodial parent to also sign a consent form.
- C. Instruct the client sign the consent before giving medications.
- D. Obtain the signature of the client’s stepfather for the surgery.
Correct Answer: A
Rationale: The correct answer is A: Obtain the permission of the custodial parent for the surgery. In this scenario, the client is a minor (16 years old), which means they are not legally able to provide informed consent for medical procedures. The custodial parent holds legal responsibility for the minor's healthcare decisions. Thus, obtaining the permission of the custodial parent is crucial to ensure valid informed consent.
Choice B is incorrect because the non-custodial parent's consent may not be legally required if the custodial parent is available to provide consent. Choice C is incorrect because obtaining consent should precede any administration of medications. Choice D is incorrect as the stepfather's consent may not hold legal weight unless designated as a legal guardian.
When caring for a patient with a pulmonary artery (PA) pressure catheter, the nurse observes that the PA waveform indicates that the catheter is in the wedged position. Which action should the nurse take next?
- A. Zero balance the transducer.
- B. Activate the fast flush system.
- C. Notify the health care provider.
- D. Deflate and reinflate the PA balloon.
Correct Answer: C
Rationale: The correct answer is C: Notify the health care provider. When the PA waveform indicates the catheter is in the wedged position, it means the catheter tip is in the pulmonary artery, potentially causing complications. The nurse should notify the healthcare provider immediately to assess and reposition the catheter to prevent further issues. Zero balancing the transducer (A) or activating the fast flush system (B) are not appropriate actions for this situation. Deflating and reinflating the PA balloon (D) could exacerbate the issue and should only be done under the guidance of the healthcare provider.