Nokea
The experienced medical-surgical nurse is being oriented to the transplant unit. Which client should the charge nurse assign to this nurse?
- A. The client who donated a kidney to a relative three (3) days ago and will be discharged in the morning.
- B. The client who had a liver transplantation three (3) days ago and was transferred from the intensive care unit two (2) hours ago.
- C. The client who received a corneal transplant four (4) hours ago and has developed a cough and is vomiting.
- D. The client who had a pancreas transplantation and has a fever, chills, and a blood glucose monitor reading of 342.
Correct Answer: A
Rationale: A stable kidney donor nearing discharge is suitable for an experienced but orienting nurse. Recent liver transplant, acute corneal transplant issues, or pancreas transplant complications require specialized care.
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The client has been in a persistent vegetative state for several years. The family, who have decided to withhold tube feedings because there is no hope of recovery, asks the nurse, 'Will the death be painful?' Which intervention should the nurse implement?
- A. Tell the family the death will be painful but the HCP can order medications.
- B. Inform the family dehydration provides a type of natural euphoria.
- C. Relate other cases where the clients have died in excruciating pain.
- D. Ask the family why they are concerned because they want the client to die anyway.
Correct Answer: B
Rationale: Dehydration in end-of-life care often leads to a natural euphoria, reducing pain perception, per hospice evidence. Painful death, case comparisons, or questioning motives is unhelpful.
The nurse is discussing advance directives with the client. The client asks the nurse, 'Why is this so important to do?' Which statement would be the nurse's best response?
- A. The federal government mandates this form must be completed by you.
- B. This will make sure your family does what you want them to do.
- C. Don't you think it is important to let everyone know your final wishes?
- D. Because of technology, there are many options for end-of-life care.
Correct Answer: D
Rationale: ADs address varied end-of-life options due to medical technology, ensuring client wishes are followed. Federal mandates, family compliance, or rhetorical questions are less accurate.
The hospice care nurse is planning the care of an elderly client diagnosed with end-stage renal disease. Which interventions should be included in the plan of care? Select all that apply.
- A. Discuss financial concerns.
- B. Assess any comorbid conditions.
- C. Monitor increased visual or auditory abilities.
- D. Note any spiritual distress.
- E. Encourage euphoria at the time of death.
Correct Answer: A,B,D
Rationale: Financial concerns, comorbidities, and spiritual distress are relevant for holistic hospice care in end-stage renal disease. Visual/auditory increases or euphoria are not typical interventions.
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.
Which client would the nurse exclude from being a potential organ/tissue donor?
- A. The 60-year-old female client with an inoperable primary brain tumor.
- B. The 45-year-old female client with a subarachnoid hemorrhage.
- C. The 22-year-old male client who has been in a motor-vehicle accident.
- D. The 36-year-male client recently released from prison.
Correct Answer: A
Rationale: Primary brain tumors contraindicate organ donation due to malignancy risk, per UNOS guidelines. Hemorrhage, trauma, or prison status do not exclude donation.