Nokea
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.
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The client receiving dialysis for end-stage renal disease wants to quit dialysis and die. Which ethical principle supports the client's right to die?
- A. Autonomy.
- B. Self-determination.
- C. Beneficence.
- D. Justice.
Correct Answer: A
Rationale: Autonomy supports a client’s right to make decisions, including refusing treatment, per ethical standards. Self-determination is synonymous, but autonomy is the precise term.
The male client in the long-term care facility has been told that he will not live for many more months. The client has been estranged from his daughter for years. He tells the nurse that he could die a happy man if he could talk to his daughter just one more time. Which statement is the nurse's best response?
- A. You should not feel bad. Things will work out for the best before your death.
- B. What did you do to make your daughter not talk to you all this time?
- C. If you would like I can try to contact your daughter and ask her to come see you.
- D. Tell me more about being unhappy that you don't have a relationship with your daughter.
Correct Answer: C
Rationale: Offering to contact the daughter supports the client’s wish, per patient-centered care. Minimizing feelings, blaming, or exploring unhappiness is less actionable.
Which tissue or organ can be repeatedly donated to clients needing a transplant?
- A. Skin.
- B. Bones.
- C. Kidneys.
- D. Bone marrow.
Correct Answer: D
Rationale: Bone marrow regenerates, allowing repeated donation. Skin, bones, and kidneys are limited or single-donation tissues/organs.
The client with an AD tells the nurse, 'I have changed my mind about my AD. I really want everything possible done if I am near death since I have a grandchild.' Which action should the nurse implement?
- A. Notify the health information systems department to talk to the client.
- B. Remove the AD from the client's chart and shred the document.
- C. Inform the client he or she has the right to revoke the AD at any time.
- D. Explain this document cannot be changed once it is signed.
Correct Answer: C
Rationale: Clients can revoke ADs at any time, per legal rights. Notifying health information, shredding without process, or claiming unchangeability is incorrect.
The client diagnosed with septicemia expired, and the family tells the nurse the client is an organ donor. Which intervention should the nurse implement?
- A. Notify the organ and tissue organizations to make the retrieval.
- B. Explain a systemic infection prevents the client from being a donor.
- C. Call and notify the health-care provider of the family's request.
- D. Take the body to the morgue until the organ bank makes a decision.
Correct Answer: B
Rationale: Systemic infections like septicemia contraindicate organ donation due to infection risk, per UNOS guidelines. Notification, HCP calls, or morgue transfer are premature.