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The wife of a client receiving hospice care being cared for at home calls the nurse to report the client is restless and agitated. Which interventions should the nurse implement? List in order of priority.
- A. Request an order from the health-care provider for antianxiety medications.
- B. Call the medical equipment company and request oxygen for the client.
- C. Go to the home and assess the client and address the wife's concerns.
- D. Reassure and calm the wife over the telephone.
- E. Notify the chaplain about the client's change in status.
Correct Answer: C,D,A,B,E
Rationale: 1) Assess client at home (determine cause of agitation); 2) Reassure wife (immediate support); 3) Request antianxiety medication (if indicated); 4) Request oxygen (if hypoxia present); 5) Notify chaplain (spiritual support).
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The nurse is orienting to a hospice organization. Which statement does not indicate a right of the terminal client? The right to:
- A. Be treated with respect and dignity.
- B. Have particulars of the death withheld.
- C. Receive optimal and effective pain management.
- D. Receive holistic and compassionate care.
Correct Answer: B
Rationale: Terminal clients have rights to dignity, pain management, and holistic care, per hospice principles. Withholding death particulars is not a recognized right and may violate transparency.
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.
The client diagnosed with diabetes mellitus type 2 wants to be an organ donor and asks the nurse, 'Which organs can I donate?' Which statement is the nurse's best response?
- A. It is wonderful you want to be an organ donor. Let's discuss this.
- B. You can donate any organ in your body, except the pancreas.
- C. You have to donate your body to science to be an organ donor.
- D. You cannot donate any organs, but you can donate some tissues.
Correct Answer: D
Rationale: Type 2 diabetes may contraindicate organ donation (e.g., kidneys, pancreas) due to vascular damage, but tissues (e.g., corneas) are often viable. Other responses are inaccurate.
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 78-year-old Catholic client is in end-stage congestive heart failure and has a DNR order. The client has AP 50, RR 10, and BP 80/50, and Cheyne-Stokes respirations. Which action should the nurse implement?
- A. Bring the crash cart to the bedside.
- B. Apply oxygen via nasal cannula.
- C. Notify a priest for last rites.
- D. Turn the bed to face the sunset.
Correct Answer: C
Rationale: Notifying a priest for last rites respects Catholic end-of-life practices, a priority with imminent death. Crash cart violates DNR, oxygen is less critical, and bed orientation is irrelevant.