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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.
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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 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 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 client received a liver transplant and is preparing for discharge. Which discharge instruction should the nurse teach?
- A. The immune-suppressant drugs must be tapered off when discontinuing them.
- B. There may be slight foul-smelling drainage on the dressing for a few days.
- C. Notify the HCP immediately if a cough or fever develops.
- D. The skin will turn yellow from the antirejection drugs.
Correct Answer: C
Rationale: Cough or fever may indicate infection, critical post-transplant due to immunosuppression. Tapering drugs, foul drainage, or jaundice are incorrect or misleading.
The nurse is discussing placing the client diagnosed with chronic obstructive pulmonary disease (COPD) in hospice care. Which prognosis must be determined to place the client in hospice care?
- A. The client is doing well but could benefit from the added care by hospice.
- B. The client has a life expectancy of six (6) months or less.
- C. The client will live for about one (1) to two (2) more years.
- D. The client has about eight (8) weeks to live and needs pain control.
Correct Answer: B
Rationale: Hospice eligibility requires a prognosis of six months or less, per Medicare guidelines. Other options do not meet this criterion.