Nokea
The nurse is discussing the HCP's recommendation for removal of life support with the client's family. Which information concerning brain death should the nurse teach the family?
- A. Positive waves on the electroencephalogram (EEG) mean the brain is dead and any further treatment is futile.
- B. When putting cold water in the ear, if the client reacts by pulling away, this demonstrates brain death.
- C. Tests will be done to determine if any brain activity exists before the machines are turned off.
- D. Although the blood flow studies don't indicate activity, the client can still come out of the coma.
Correct Answer: C
Rationale: Brain death requires tests (e.g., EEG, apnea test) to confirm no brain activity, per medical standards. Positive EEG waves, caloric reflex, or coma recovery are incorrect.
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The nurse is teaching a class on chronic pain to new graduates. Which information is most important for the nurse to discuss?
- A. The nurse must believe the client's report of pain.
- B. Clients in chronic pain may not show objective signs.
- C. Alternate pain-control therapies are used for chronic pain.
- D. Referral to a pain clinic may be necessary.
Correct Answer: A
Rationale: Believing the client’s pain report is critical, as pain is subjective, per pain management guidelines. Objective signs, therapies, or referrals are secondary.
The nurse is orienting to a hospice organization. Which statement does not indicate a right of the terminal client? The right to:
- A. Be treated with respect and dignity.
- B. Have particulars of the death withheld.
- C. Receive optimal and effective pain management.
- D. Receive holistic and compassionate care.
Correct Answer: B
Rationale: Terminal clients have rights to dignity, pain management, and holistic care, per hospice principles. Withholding death particulars is not a recognized right and may violate transparency.
The family is dealing with the imminent death of the client. Which information is most important for the nurse to discuss when planning interventions for the grieving process?
- A. How angry are the family members about the death?
- B. Which family member will be making decisions?
- C. What previous coping skills have been used?
- D. What type of funeral service has been planned?
Correct Answer: C
Rationale: Previous coping skills inform tailored grief interventions, per nursing process. Anger, decision-makers, or funeral plans are less critical initially.
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 intensive care nurse is caring for a deceased client who is an organ donor, and the organ donation team is en route to the hospital. Which statement would be an appropriate goal of treatment for the client?
- A. The urinary output is 20 mL/hr via a Foley catheter.
- B. The systolic blood pressure is greater than 90 mm Hg.
- C. The pulse oximeter reading remains between 88% and 90%.
- D. The telemetry shows the client in sinus tachycardia.
Correct Answer: B
Rationale: Maintaining systolic BP >90 mm Hg ensures organ perfusion, a key goal for donation. Urine output, oximetry, or tachycardia are less critical post-death.