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A nurse is caring for a child who has a prescription for a blood transfusion. The child's parents have refused the treatment due to their religious beliefs. Which of the following actions should the nurse take?
- A. Examine personal values about the issue.
- B. Tell the parents that this is a necessary procedure.
- C. Inform the parents that the staff does not require their consent.
- D. Contact a spiritual support person to explain the importance of the procedure.
Correct Answer: A
Rationale: The correct answer is A: Examine personal values about the issue. The nurse should first reflect on their own values to ensure they can provide care without bias. This allows the nurse to approach the situation with empathy and understanding. Choice B is incorrect because it disregards the parents' beliefs. Choice C is incorrect as parental consent is typically required for medical procedures involving minors. Choice D may not be effective as it may come across as disrespectful to the parents' beliefs.
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A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
- A. Place a name tag on the body.
- B. Obtain the pronouncement of death from the provider.
- C. Remove tubes and indwelling lines.
- D. Wash the client's body.
- E. Ask the client's family members if they would like to view the body.
Correct Answer: B, E, C, D, A
Rationale: 1. Obtain the pronouncement of death from the provider (B): This is the first step to officially confirm the client's passing.
2. Ask the client's family members if they would like to view the body (E): Providing support to the family is crucial.
3. Remove tubes and indwelling lines (C): This step is necessary to prepare the body for respectful handling.
4. Wash the client's body (D): Maintaining dignity and cleanliness is important.
5. Place a name tag on the body (A): This ensures proper identification for all involved.
In summary, obtaining the pronouncement of death is the priority, followed by addressing the emotional needs of the family, preparing the body, and ensuring proper identification. Removing tubes and washing the body come before placing the name tag.
A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, 'What would happen if I arrived at the emergency department and I had difficulty breathing?' Which of the following responses should the nurse make?
- A. We would consult the person appointed by your health care proxy to make decisions.
- B. We would give you oxygen through a tube in your nose.
- C. You would be unable to change your previous wishes about your care.
- D. We would insert a breathing tube while we evaluate your condition.
Correct Answer: A
Rationale: The correct answer is A: We would consult the person appointed by your health care proxy to make decisions. This response aligns with the client's living will and respects their wishes for declining resuscitation. By involving the designated health care proxy, the healthcare team ensures that decisions are made in accordance with the client's preferences.
Choice B is incorrect because providing oxygen through a tube does not address the client's concerns about declining resuscitation. Choice C is incorrect as it does not address the client's current situation or need for support in the emergency department. Choice D is incorrect as it goes against the client's expressed wishes in the living will. It is important to prioritize the client's autonomy and respect their decisions regarding end-of-life care.
A nurse is talking with an older adult client who is contemplating retirement. The client states, 'I keep thinking about how much I enjoy my job. I'm not sure I want to retire.' Which of the following responses should the nurse make?
- A. You would have so much more time to spend with your family.'
- B. You should consider getting a part-time job or doing volunteer work.'
- C. Let's talk about how the change in your job status will affect you.'
- D. Why wouldn't you want to retire and relax?
Correct Answer: C
Rationale: The correct response is C: "Let's talk about how the change in your job status will affect you." This response shows empathy and understanding towards the client's concerns and opens up a dialogue to explore the client's feelings and thoughts about retirement. It allows the nurse to assess the client's emotional readiness and concerns, facilitating a supportive conversation.
Other choices are incorrect:
A: This response assumes that the client's main concern is spending time with family, which may not be the case.
B: While volunteering or working part-time are valid options, this response does not address the client's current feelings and may come across as dismissive.
D: This response is judgmental and does not acknowledge the client's perspective or concerns, potentially shutting down communication.
A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?
- A. Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter.
- B. Regulate oxygen via nasal cannula at flow rate of no more than 6 L/min.
- C. Make sure the reservoir bag of a partial rebreathing mask remains deflated.
- D. Use petroleum jelly to lubricate the client's nares face and lips.
Correct Answer: B
Rationale: The correct answer is B: Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min. This is the appropriate action for administering oxygen therapy to prevent oxygen toxicity. Oxygen should be delivered at the lowest effective flow rate to minimize the risk of complications. Choices A, C, and D are incorrect. A is incorrect because the flow rate should be aligned with the bottom of the ball in the flow meter, not the top. C is incorrect because the reservoir bag of a partial rebreathing mask should be inflated to ensure adequate oxygen delivery. D is incorrect because petroleum jelly should not be used in oxygen therapy due to the risk of fire hazard.
A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain?
- A. Is your pain constant or intermittent?
- B. What would you rate your pain on a scale of 0 to 10?
- C. Does the pain radiate?
- D. Is your pain sharp or dull?
Correct Answer: D
Rationale: The correct answer is D: "Is your pain sharp or dull?" This question helps the nurse determine the characteristic of the pain, which is crucial in identifying the underlying cause. Sharp pain is often associated with acute conditions like nerve irritation, whereas dull pain may indicate musculoskeletal issues. Choices A, B, and C are important in pain assessment but do not specifically address the quality of pain. Asking about pain intensity (choice B) or radiation (choice C) can provide valuable information but do not directly address whether the pain is sharp or dull. Therefore, option D is the most appropriate for assessing the quality of the client's pain in this scenario.