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 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.
The nurse is obtaining the client’s signature on a surgical permit form. The nurse determines the client does not understand the surgical procedure and possible risks. Which action should the nurse take first?
- A. Notify the client's surgeon.
- B. Document the information in the chart.
- C. Contact the operating room staff.
- D. Explain the procedure to the client.
Correct Answer: A
Rationale: Notifying the surgeon ensures informed consent, as the surgeon must clarify risks and procedures. Documentation, OR contact, or nurse explanation is secondary.
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 client diagnosed with cancer is experiencing severe pain. Which regimen would the nurse teach the client about to control the pain?
- A. Nonsteroidal anti-inflammatory drugs (NSAIDs) around the clock with narcotics used for severe pain.
- B. Morphine sustained release, a narcotic, routinely with a liquid morphine preparation for breakthrough pain.
- C. Extra-Strength Tylenol, a nonnarcotic analgesic, plus therapy to learn alternative methods of pain control.
- D. Demerol, an opioid narcotic, every six (6) hours orally with a suppository when the pain is not controlled.
Correct Answer: B
Rationale: Sustained-release morphine with breakthrough doses is standard for cancer pain, per WHO pain ladder. NSAIDs, Tylenol, or Demerol regimens are less effective or outdated.
The nurse is moving to another state which is part of the multistate licensure compact. Which information regarding ADs should the nurse be aware of when practicing nursing in other states?
- A. The laws regarding ADs are the same in all the states.
- B. Advance directives can be transferred from state to state.
- C. A significant other can sign a loved one's advance directive.
- D. Advance directives are state regulated, not federally regulated.
Correct Answer: D
Rationale: ADs are governed by state laws, varying in requirements and execution, not federal regulation. Laws differ, transferability depends on state reciprocity, and significant others cannot sign unless designated.