Nokea
The nurse is presenting an in-service discussing do not resuscitate (DNR) orders and advance directives. Which statement should the nurse discuss with the class?
- A. Advance directives must be notarized by a notary public.
- B. The client must use an attorney to complete the advanced directive.
- C. Once the DNR is written, it can be used for every hospital admission.
- D. The health-care provider must write the DNR order in the client's chart.
Correct Answer: D
Rationale: A DNR order requires a physician's written order in the chart to be actionable, per hospital policy. Notarization and attorneys are not required, and DNRs are typically re-evaluated per admission.
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Which act protects the nurse against a malpractice claim when the nurse stops at a motor-vehicle accident and renders emergency care?
- A. The Health Insurance Portability and Accountability Act.
- B. The State Nurse Practice Act.
- C. The Emergency Rendering Aid Act.
- D. The Good Samaritan Act.
Correct Answer: D
Rationale: The Good Samaritan Act protects nurses providing emergency care voluntarily, limiting malpractice liability. HIPAA, Nurse Practice Act, or fictional acts don’t apply.
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.
The nurse must be knowledgeable of ethical principles. Which is an example of the ethical principle of justice?
- A. The nurse administers a placebo, and the client asks if it will help the pain.
- B. The nurse accepts a work assignment in an area in which he or she is not experienced.
- C. The nurse refuses to tell a family member the client has a positive HIV test.
- D. The nurse provides an indigent client with safe and appropriate nursing care.
Correct Answer: D
Rationale: Justice ensures equitable care, like providing safe care to an indigent client. Placebos (deception), incompetence, or confidentiality are unrelated to justice.
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.
The client had a mastectomy and lymph node dissection three (3) years ago and has experienced postmastectomy pain (PMP) since. Which intervention should the nurse implement?
- A. Have the client see a psychologist because the pain is not real.
- B. Tell the client the pain is the cancer coming back.
- C. Refer the client to a physical therapist to prevent a frozen shoulder.
- D. Discuss changing the client to a more potent narcotic medication.
Correct Answer: C
Rationale: PMP can lead to shoulder immobility; physical therapy prevents frozen shoulder, per evidence-based practice. Psychological dismissal, cancer assumptions, or narcotics are inappropriate.