Nokea
The nurse is caring for a dying client and the family. The male client is Muslim. Which intervention should the nurse implement at the time of death?
- A. Allow the wife to stay in the room during postmortem care.
- B. Call the client's imam to perform last rites when the client dies.
- C. Place incense around the bed, but do not allow anyone to light it.
- D. Do not touch the body, and have the male family members perform care.
Correct Answer: D
Rationale: In Muslim tradition, family (often male) may perform postmortem care, respecting cultural practices. Wife’s presence, imam’s role, or incense are less specific.
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Which client would be most likely to complete an advance directive?
- A. A 55-year-old Caucasian person who is a bank president.
- B. A 34-year-old Asian licensed practical nurse.
- C. A 22-year-old Hispanic lawn care worker.
- D. A 65-year-old African American retired cook.
Correct Answer: D
Rationale: Older adults (e.g., 65-year-old) are more likely to complete ADs due to increased awareness of mortality and health issues, regardless of ethnicity or profession.
The client is three (3) hours post-heart transplantation. Which data would support a complication of this procedure?
- A. The client has nausea after taking the oral antirejection medication.
- B. The client has difficulty coming off the heart-lung bypass machine.
- C. The client has saturated three (3) ABD dressing pads in one (1) hour.
- D. The client complains of pain at a '6' on a 1-to-10 scale.
Correct Answer: C
Rationale: Excessive bleeding (saturated dressings) indicates a surgical complication, requiring urgent intervention. Nausea, bypass difficulty, or moderate pain are less immediate.
The male client asks the nurse, 'Should I designate my wife as durable power of attorney for health care?' Which statement would be the nurse's best response?
- A. Yes, she should be because she is your next of kin.
- B. Most people don't allow their spouse to do this.
- C. Will your wife be able to support your wishes?
- D. Your children are probably the best ones for the job.
Correct Answer: C
Rationale: Choosing a proxy involves ensuring they’ll honor the client’s wishes, a key consideration. Kinship, rarity, or children are less relevant without this focus.
The client diagnosed with diabetes mellitus type 2 wants to be an organ donor and asks the nurse, 'Which organs can I donate?' Which statement is the nurse's best response?
- A. It is wonderful you want to be an organ donor. Let's discuss this.
- B. You can donate any organ in your body, except the pancreas.
- C. You have to donate your body to science to be an organ donor.
- D. You cannot donate any organs, but you can donate some tissues.
Correct Answer: D
Rationale: Type 2 diabetes may contraindicate organ donation (e.g., kidneys, pancreas) due to vascular damage, but tissues (e.g., corneas) are often viable. Other responses are inaccurate.
The nurse is caring for clients on a medical floor. Which client should the nurse assess first after the shift report?
- A. The client with arterial blood gases of pH 7.36, Paco2 40, HCO3 26, Pao2 90.
- B. The client with vital signs of T 99°F, P 101, R 28, and BP 120/80.
- C. The client complaining of pain at a '10' on a 1-to-10 scale who can't localize it.
- D. The client who is postappendectomy with pain at a '3' on a 1-to-10 scale.
Correct Answer: C
Rationale: Severe pain (10/10), especially nonlocalizable, may indicate a serious condition (e.g., ischemia), requiring immediate assessment. Normal ABGs, mild vital sign changes, or mild post-op pain are less urgent.