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The spouse of a client dying from lung cancer states, 'I don't understand this death rattle. She has not had anything to drink in days. Where is the fluid coming from?' Which is the hospice care nurse's best response?
- A. The body produces about two (2) teaspoons of fluid every minute on its own.
- B. Are you sure someone is not putting ice chips in her mouth?
- C. There is no reason for this, but it does happen from time to time.
- D. I can administer a patch to her skin to dry up the secretions if you wish.
Correct Answer: C
Rationale: The death rattle results from accumulated secretions in the throat, a normal end-of-life phenomenon, not fluid intake. Teaspoon estimates, ice chips, or patches are inaccurate or premature.
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Which entity mandates the registered nurse's behavior when practicing professional nursing?
- A. The state's Nurse Practice Act.
- B. Client's Bill of Rights.
- C. The United States legislature.
- D. American Nurses Association.
Correct Answer: A
Rationale: The state’s Nurse Practice Act defines legal scope and behavior for nurses, enforceable by law. Other entities provide guidelines, not mandates.
The client tells the nurse, 'Every time I come in the hospital you hand me one of these advance directives (AD). Why should I fill one of these out?' Which statement by the nurse is most appropriate?
- A. You must fill out this form because Medicare laws require it.
- B. An AD lets you participate in decisions about your health care.
- C. This paper will ensure no one can override your decisions.
- D. It is part of the hospital admission packet and I have to give it to you.
Correct Answer: B
Rationale: Advance directives allow clients to specify their health care preferences, ensuring participation in decisions, per the Patient Self-Determination Act. Medicare requires offering, not completing, ADs; no document guarantees non-override; and packet inclusion is procedural, not the reason.
The experienced medical-surgical nurse is being oriented to the transplant unit. Which client should the charge nurse assign to this nurse?
- A. The client who donated a kidney to a relative three (3) days ago and will be discharged in the morning.
- B. The client who had a liver transplantation three (3) days ago and was transferred from the intensive care unit two (2) hours ago.
- C. The client who received a corneal transplant four (4) hours ago and has developed a cough and is vomiting.
- D. The client who had a pancreas transplantation and has a fever, chills, and a blood glucose monitor reading of 342.
Correct Answer: A
Rationale: A stable kidney donor nearing discharge is suitable for an experienced but orienting nurse. Recent liver transplant, acute corneal transplant issues, or pancreas transplant complications require specialized care.
The nurse is admitting a client to the medical surgical unit. Which is required to be offered to the client if the hospital accepts Medicare reimbursement?
- A. The opportunity to make an advance directive.
- B. The client must be referred to a case manager.
- C. The client must apply for a Medicare supplement insurance.
- D. The opportunity to discuss end-of-life issues.
Correct Answer: A
Rationale: The Patient Self-Determination Act mandates offering ADs on admission for Medicare-funded hospitals. Case management, insurance, or end-of-life discussions are not required.
The nurse is discussing advance directives with the client. The client asks the nurse, 'Why is this so important to do?' Which statement would be the nurse's best response?
- A. The federal government mandates this form must be completed by you.
- B. This will make sure your family does what you want them to do.
- C. Don't you think it is important to let everyone know your final wishes?
- D. Because of technology, there are many options for end-of-life care.
Correct Answer: D
Rationale: ADs address varied end-of-life options due to medical technology, ensuring client wishes are followed. Federal mandates, family compliance, or rhetorical questions are less accurate.