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The nurse is caring for the family of the client who has just died. Which is the nurse's priority action?
- A. Be with the family.
- B. Call the funeral home.
- C. Notify the minister.
- D. Fill out the death certificate.
Correct Answer: A
Rationale: Being with the family provides immediate emotional support, a nursing priority post-death. Funeral, minister, or certificate tasks are secondary.
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Which action by the unlicensed assistive personnel (UAP) would warrant immediate intervention by the nurse?
- A. The UAP is holding the phone to the ear of a client who is a quadriplegic.
- B. The UAP refuses to discuss the client's condition with the visitor in the room.
- C. The UAP put a vest restraint on an elderly client found wandering in the hall.
- D. The UAP is assisting the client with arthritis to open up personal mail.
Correct Answer: C
Rationale: Applying restraints without a physician’s order violates safety and legal standards, requiring intervention. Other actions are appropriate UAP tasks.
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.
Which entity mandates the registered nurse's behavior when practicing professional nursing?
- A. The state's Nurse Practice Act.
- B. Client's Bill of Rights.
- C. The United States legislature.
- D. American Nurses Association.
Correct Answer: A
Rationale: The state’s Nurse Practice Act defines legal scope and behavior for nurses, enforceable by law. Other entities provide guidelines, not mandates.
Which document is the best professional source to provide direction for a nurse when addressing ethical issues and behavior?
- A. The Hippocratic Oath.
- B. The Nuremberg Code.
- C. Home Health Care Bill of Rights.
- D. ANA Code of Ethics.
Correct Answer: D
Rationale: The ANA Code of Ethics guides nurses on ethical behavior and decision-making, specific to nursing practice. Other documents are less relevant or outdated.
The mother of a 20-year-old African American male client receiving dialysis asks the nurse, 'My son has been on the transplant list longer than that white woman. Why did she get the kidney?' Which statement is the nurse's best response?
- A. The woman was famous, and so more people will donate organs now.
- B. I understand you are upset your son is ill. Would you like to talk?
- C. No one knows who gets an organ. You just have to wait and pray.
- D. The tissues must match or the body will reject the kidney and it will be wasted.
Correct Answer: D
Rationale: Tissue matching (HLA compatibility) determines transplant priority, preventing rejection, per UNOS guidelines. Fame, empathy, or fatalism are inappropriate responses.