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Which action by the unlicensed assistive personnel (UAP) would warrant immediate intervention by the nurse?
- A. The UAP is holding the phone to the ear of a client who is a quadriplegic.
- B. The UAP refuses to discuss the client's condition with the visitor in the room.
- C. The UAP put a vest restraint on an elderly client found wandering in the hall.
- D. The UAP is assisting the client with arthritis to open up personal mail.
Correct Answer: C
Rationale: Applying restraints without a physician’s order violates safety and legal standards, requiring intervention. Other actions are appropriate UAP tasks.
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The nurse is giving an in-service on end-of-life issues. Which activity should the nurse encourage the participants to perform?
- A. Discuss with another participant the death of a client.
- B. Review the hospital postmortem care policy.
- C. Justify not putting the client in a shroud after dying.
- D. Write down their own beliefs about death and dying.
Correct Answer: D
Rationale: Writing personal beliefs fosters self-awareness, enhancing end-of-life care competence. Client death discussions, policy review, or shroud justification are less introspective.
The nurse is obtaining the client’s signature on a surgical permit form. The nurse determines the client does not understand the surgical procedure and possible risks. Which action should the nurse take first?
- A. Notify the client's surgeon.
- B. Document the information in the chart.
- C. Contact the operating room staff.
- D. Explain the procedure to the client.
Correct Answer: A
Rationale: Notifying the surgeon ensures informed consent, as the surgeon must clarify risks and procedures. Documentation, OR contact, or nurse explanation is secondary.
The hospice care nurse is conducting a spiritual care assessment. Which statement is the scientific rationale for this intervention?
- A. The client will ask all of his or her spiritual questions and get answers.
- B. The nurse is able to explain to the client how death will affect the spirit.
- C. Spirituality provides a sense of meaning and purpose for many clients.
- D. The nurse is the expert when assisting the client with spiritual matters.
Correct Answer: C
Rationale: Spirituality offers meaning and purpose, supporting holistic hospice care. Clients may not ask all questions, nurses aren’t spiritual experts, and death’s spiritual impact is subjective.
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 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.