The pregnant client asks the nurse about banking the cord blood. Which information should the nurse teach the client?
- A. The procedure involves a lot of pain with a very poor result.
- B. The client must deliver at a large public hospital to do this.
- C. The client will be charged a yearly storage fee on the cells.
- D. The stem cells can be stored for about four (4) years before they ruin.
Correct Answer: C
Rationale: Cord blood banking involves annual storage fees for stem cells, per industry standards. Pain, hospital requirements, or four-year limits are inaccurate.
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The nurse is caring for a client who is confused and fell trying to get out of bed. There is no family at the client's bedside. Which action should the nurse implement first?
- A. Contact a family member to come and stay with the client.
- B. Administer a sedative medication to the client.
- C. Place the client in a chair with a sheet tied around him or her.
- D. Notify the health-care provider to obtain a restraint order.
Correct Answer: D
Rationale: Notifying the HCP for a restraint order ensures safety and legal compliance for a confused client at risk of falls. Family contact, sedation, or makeshift restraints are unsafe or secondary.
The nurse and an unlicensed assistive personnel (UAP) are caring for clients on a postoperative transplant unit. Which task should the nurse delegate to the UAP?
- A. Assess the hourly outputs of the client who is post-kidney transplantation.
- B. Raise the head of the bed for a client who is post-liver transplantation.
- C. Monitor the serum blood studies of a client who has rejected an organ.
- D. Irrigate the nasogastric tube of the client who had a pancreas transplant.
Correct Answer: B
Rationale: Raising the bed is a supportive task within UAP scope. Assessing outputs, monitoring labs, or irrigating NG tubes requires nursing judgment.
The female client in the oncology clinic tells the nurse she has a great deal of pain but does not like to take pain medication. Which action should the nurse implement first?
- A. Tell the client it is important for her to take her medication.
- B. Find out how the client has been dealing with the pain.
- C. Have the HCP tell the client to take the pain medications.
- D. Instruct the client not to worry-the pain will resolve itself.
Correct Answer: B
Rationale: Assessing coping strategies informs a tailored pain management plan, respecting client preferences. Forcing medication, HCP involvement, or dismissing pain is premature.
The client with an AD tells the nurse, 'I have changed my mind about my AD. I really want everything possible done if I am near death since I have a grandchild.' Which action should the nurse implement?
- A. Notify the health information systems department to talk to the client.
- B. Remove the AD from the client's chart and shred the document.
- C. Inform the client he or she has the right to revoke the AD at any time.
- D. Explain this document cannot be changed once it is signed.
Correct Answer: C
Rationale: Clients can revoke ADs at any time, per legal rights. Notifying health information, shredding without process, or claiming unchangeability is incorrect.
The nurse is discussing malpractice issues in an in-service class. Which situation is an example of malpractice?
- A. The nurse fails to report a neighbor who is abusing his two children.
- B. The nurse does not intervene in a client who has a BP of 80/50 and AP of 122.
- C. The nurse is suspected of taking narcotics prescribed for a client.
- D. The nurse falsifies vital signs in the client's medical records.
Correct Answer: B
Rationale: Malpractice involves breaching the standard of care causing harm, like ignoring hypotension and tachycardia. Child abuse reporting, narcotic theft, or falsification are ethical/legal issues, not malpractice.