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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.
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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 pronounced Dr. Smith's client to be clinically dead. Which should the nurse document on the client's chart?
- A. Brain scan indicates no brain wave activity, client pronounced deceased. Family refuses to talk with organ bank.
- B. Cardiac arrest noted, CPR initiated but unsuccessful. Pronounced dead.
- C. Pulse, respirations, and blood pressure absent at 0900, pronounced dead. Dr. Smith to sign death certificate.
- D. Client found without pulse, body cold to touch. Pronounced deceased at 0900.
Correct Answer: C
Rationale: Documentation should include objective findings (absent vital signs), time, and physician’s role, per legal standards. Brain scan or CPR details are specific, and cold body is insufficient.
The HCP has notified the family of a client in a persistent vegetative state on a ventilator of the need to 'pull the plug.' The client does not have an AD or a durable power of attorney for health care, and the family does not want their loved one removed from the ventilator. Which action should the nurse implement?
- A. Refer the case to the hospital ethics committee.
- B. Tell the family they must do what the HCP orders.
- C. Follow the HCP's order and 'pull the plug.'
- D. Determine why the client did not complete an AD.
Correct Answer: A
Rationale: Without an AD or proxy, disagreements between family and HCP require ethics committee review for resolution. Forcing compliance, following orders against family wishes, or investigating AD absence is inappropriate.
The client is in the psychiatric unit in a medical center. Which action by the psychiatric nurse is a violation of the client's legal and civil rights?
- A. The nurse tells the client civilian clothes can be worn on the unit.
- B. The nurse allows the client to have family visits during visiting hours.
- C. The nurse delivers unopened mail and packages to the client.
- D. The nurse listens to the client talking on the telephone to a friend.
Correct Answer: D
Rationale: Eavesdropping on a client’s phone call violates privacy rights, per civil liberties. Allowing clothes, visits, or mail respects client autonomy.
The charge nurse is making assignments on an oncology floor. Which client should be assigned to the most experienced nurse?
- A. The client diagnosed with leukemia who has a hemoglobin of 6 g/dL.
- B. The client diagnosed with lung cancer with a pulse oximeter reading of 89%.
- C. The client diagnosed with colon cancer who needs the colostomy irrigated.
- D. The client diagnosed with Kaposi's sarcoma who is yelling at the staff.
Correct Answer: A
Rationale: Hemoglobin of 6 g/dL indicates severe anemia, requiring complex monitoring and transfusion, best handled by an experienced nurse. Hypoxia, colostomy care, or behavior are less acute.