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The primary nurse caring for the client who died is crying with the family at the bedside. Which action should the charge nurse implement?
- A. Request the primary nurse to come out in the hall.
- B. Refer the nurse to the employee assistance program.
- C. Allow the nurse and family this time to grieve.
- D. Ask the chaplain to relieve the nurse at the bedside.
Correct Answer: C
Rationale: Allowing the nurse to grieve with the family supports emotional bonding, unless it impairs care. Removing, referring, or replacing the nurse may disrupt this moment.
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The male client in the long-term care facility has been told that he will not live for many more months. The client has been estranged from his daughter for years. He tells the nurse that he could die a happy man if he could talk to his daughter just one more time. Which statement is the nurse's best response?
- A. You should not feel bad. Things will work out for the best before your death.
- B. What did you do to make your daughter not talk to you all this time?
- C. If you would like I can try to contact your daughter and ask her to come see you.
- D. Tell me more about being unhappy that you don't have a relationship with your daughter.
Correct Answer: C
Rationale: Offering to contact the daughter supports the client’s wish, per patient-centered care. Minimizing feelings, blaming, or exploring unhappiness is less actionable.
Which action should the nurse implement for the Chinese client's family who are requesting to light incense around the dying client?
- A. Suggest the family bring potpourri instead of incense.
- B. Tell the client the door must be shut at all times.
- C. Inform the family the scent will make the client nauseated.
- D. Explain the fire code does not allow any burning in a hospital.
Correct Answer: D
Rationale: Fire codes prohibit burning incense in hospitals, a safety-based explanation. Potpourri, door closure, or nausea claims are less accurate or dismissive.
The client diagnosed with septicemia expired, and the family tells the nurse the client is an organ donor. Which intervention should the nurse implement?
- A. Notify the organ and tissue organizations to make the retrieval.
- B. Explain a systemic infection prevents the client from being a donor.
- C. Call and notify the health-care provider of the family's request.
- D. Take the body to the morgue until the organ bank makes a decision.
Correct Answer: B
Rationale: Systemic infections like septicemia contraindicate organ donation due to infection risk, per UNOS guidelines. Notification, HCP calls, or morgue transfer are premature.
The Hispanic client who has terminal cancer is requesting a curandero to come to the bedside. Which intervention should the nurse implement?
- A. Tell the client it is against policy to allow faith healers.
- B. Assist with planning the visit from the curandero.
- C. Refer the client to the pastoral care department.
- D. Determine the reason the client needs the curandero.
Correct Answer: B
Rationale: Facilitating a curandero visit respects Hispanic cultural beliefs, per patient-centered care. Denying, referring, or questioning the need is less culturally sensitive.
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.