Nokea
Which of the following statements should the nurse make?
- A. We can initiate medical care until you get legal assistance in preparing your advance directives.
- B. Advance directives can be signed without legal representation.
- C. Advance directives can be a verbal agreement between you and your provider until legal review can be obtained.
- D. A social worker will assist you to find affordable legal representation.
Correct Answer: B
Rationale: The correct answer is B: Advance directives can be signed without legal representation. This is correct because advance directives are legal documents that individuals can complete on their own without the need for a lawyer. They allow individuals to specify their healthcare wishes in advance. Choice A is incorrect as medical care can be initiated regardless of advance directives. Choice C is incorrect as advance directives must be in writing to be legally valid. Choice D is incorrect as social workers typically provide support but do not usually offer legal representation.
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Which of the following actions should the nurse take? Select all that apply.
- A. Have a second nurse confirm the information on the blood label
- B. Insert a large bore IV catheter
- C. Witness the client signing a consent for transfusion.
- D. Flush the transfusion tubing with dextrose SM in water.
- E. Explain to the client that transfusion reactions are not serious
Correct Answer: A,B
Rationale: The correct actions are A and B. A second nurse confirming the information on the blood label ensures accuracy and prevents errors. Inserting a large bore IV catheter allows for rapid transfusion and prevents complications. Choice C ensures informed consent but is not directly related to the transfusion process. Choice D is incorrect because dextrose cannot be used to flush transfusion tubing. Choice E is incorrect as it provides inaccurate information to the client.
Which of the following statements by the parent indicates an understanding of the teaching?
- A. After 5 to 10 minutes when the breast is emptied, my baby should be removed from the breast.â€
- B. Manually expressing my milk will decrease my milk supply.
- C. My baby should always start on the same breast when feeding.â€
- D. The more my baby is at the breast sucking, the mare milk I will produce.â€
Correct Answer: D
Rationale: The correct answer is D because it reflects an understanding of the concept of supply and demand in breastfeeding. The statement acknowledges that the more the baby suckles, the more milk the parent will produce. This aligns with the principle that frequent and effective nursing stimulates milk production.
Choice A is incorrect because it suggests limiting nursing time, which can hinder milk production. Choice B is incorrect as manual expression can actually help increase milk supply. Choice C is incorrect as it is recommended to offer both breasts during a feeding session to ensure the baby receives enough hindmilk.
Which of the following actions by the newly licensed nurse requires intervention by the staff nurse?
- A. Waits for 2 min between suctions
- B. Encourages the client to cough during suctioning
- C. Applies suction for 15 seconds
- D. Inserts the catheter without applying suction
Correct Answer: C
Rationale: Suctioning longer than 10-15 seconds risks hypoxia.
A nurse is caring for a client who asks for information regarding organ donation. Which of the following responses should the nurse make?
- A. I cannot be a witness for your consent to donate.
- B. You must be at least 21, years of age to become an organ donorâ€
- C. Your desire to be an organ donor must be documented in writingâ€
- D. Your name cannot be removed once you are listed on the organ donor list.
Correct Answer: C
Rationale: The correct response should be C: "Your desire to be an organ donor must be documented in writing." This is the correct answer because in order for someone to become an organ donor, their decision must be documented in writing, typically through an organ donor card, a driver's license designation, or registration with a national organ donation registry. This documentation is crucial to ensure that the individual's wishes are respected and followed in the event of their death.
The other choices are incorrect:
A: "I cannot be a witness for your consent to donate." This statement is incorrect as a nurse can provide information and support regarding organ donation, but they are not required to be a witness for consent.
B: "You must be at least 21 years of age to become an organ donor." This statement is incorrect as the legal age requirement to become an organ donor varies by country or state, and it is not always 21 years of age.
D: "Your name cannot be removed once you are listed
A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?
- A. A client who is scheduled for a procedure in 1 hr
- B. A client who received a pain medication 30 min ago for postoperative pain
- C. A client who was just given a glass of orange juice far a low blood glucose level
- D. A client who has 100 mL of fluid remaining in his IV bag
Correct Answer: C
Rationale: The correct answer is C. The nurse should assess the client who just drank orange juice for a low blood glucose level first because hypoglycemia can lead to serious complications like seizures or loss of consciousness. Assessing and addressing the client's blood glucose level promptly is crucial to prevent harm.
Choice A is not the priority as the client scheduled for a procedure in 1 hour can wait for assessment until after the client with low blood glucose is evaluated.
Choice B, the client who received pain medication 30 minutes ago, can be assessed after the client with low blood glucose since the medication's effects have likely already taken place.
Choice D, the client with 100 mL of fluid remaining in the IV bag, can also wait for assessment as it does not pose an immediate threat to the client's health compared to low blood glucose.
Therefore, prioritizing the assessment of the client with low blood glucose is crucial to ensure their safety and well-being.