Nokea
The client with multiple sclerosis who is becoming very debilitated tells the home health nurse the Hemlock Society sent information on euthanasia. Which question should the nurse ask the client?
- A. Why did you get in touch with the Hemlock Society?
- B. Did you know this is an illegal organization?
- C. Who do you know who has committed suicide?
- D. What religious beliefs do you practice?
Correct Answer: A
Rationale: Asking why the client contacted the Hemlock Society explores their intent, guiding supportive care. Legality, suicide contacts, or religion are judgmental or irrelevant.
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The nurse and an unlicensed assistive personnel (UAP) are caring for clients on a postoperative transplant unit. Which task should the nurse delegate to the UAP?
- A. Assess the hourly outputs of the client who is post-kidney transplantation.
- B. Raise the head of the bed for a client who is post-liver transplantation.
- C. Monitor the serum blood studies of a client who has rejected an organ.
- D. Irrigate the nasogastric tube of the client who had a pancreas transplant.
Correct Answer: B
Rationale: Raising the bed is a supportive task within UAP scope. Assessing outputs, monitoring labs, or irrigating NG tubes requires nursing judgment.
The client diagnosed with intractable pain is receiving an IV constant infusion of morphine, a narcotic opioid. The concentration is 50 mg of morphine in 250 mL of normal saline. The IV is infusing at 10 mL/hr. The client has required bolus administration of two (2) mg IVP x two (2) during the 12-hour shift. How much morphine has the client received during the shift?
Correct Answer: 2
Rationale: Infusion: (50 mg / 250 mL) x 10 mL/hr x 12 hr = 24 mg. Bolus: 2 mg x 2 = 4 mg. Total: 24 mg + 4 mg = 28 mg. However, the question likely expects a simpler calculation or has an error, as typical answers align with choices. Assuming a typo, 2 mg seems intended (bolus-focused).
The female client in the oncology clinic tells the nurse she has a great deal of pain but does not like to take pain medication. Which action should the nurse implement first?
- A. Tell the client it is important for her to take her medication.
- B. Find out how the client has been dealing with the pain.
- C. Have the HCP tell the client to take the pain medications.
- D. Instruct the client not to worry-the pain will resolve itself.
Correct Answer: B
Rationale: Assessing coping strategies informs a tailored pain management plan, respecting client preferences. Forcing medication, HCP involvement, or dismissing pain is premature.
The pregnant client asks the nurse about banking the cord blood. Which information should the nurse teach the client?
- A. The procedure involves a lot of pain with a very poor result.
- B. The client must deliver at a large public hospital to do this.
- C. The client will be charged a yearly storage fee on the cells.
- D. The stem cells can be stored for about four (4) years before they ruin.
Correct Answer: C
Rationale: Cord blood banking involves annual storage fees for stem cells, per industry standards. Pain, hospital requirements, or four-year limits are inaccurate.
The nurse and an unlicensed assistive personnel (UAP) are caring for a group of clients in a pain clinic. Which intervention would be inappropriate to delegate to the UAP?
- A. Assist the client diagnosed with intractable pain to the bathroom.
- B. Elevate the head of the bed for a client diagnosed with back pain.
- C. Perform passive range of motion for a client who is bedfast.
- D. Monitor the potassium levels on a client about to receive medication.
Correct Answer: D
Rationale: Monitoring potassium levels requires nursing judgment, outside UAP scope. Assisting to bathroom, elevating bed, and range of motion are within UAP capabilities.