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Which situation would cause the nurse to question the validity of an AD when caring for the elderly client?
- A. The client's child insists the client make his or her own decisions.
- B. The nurse observes the wife making the husband sign the AD.
- C. A nurse encouraged the client to think about end-of-life decisions.
- D. A friend witnesses the client's signature on the AD form.
Correct Answer: B
Rationale: Coercion (wife forcing signature) invalidates an AD, as it must reflect the client’s voluntary wishes. Child insistence, nurse encouragement, or friend witnessing is acceptable.
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Which action by the primary nurse would require the unit manager to intervene?
- A. The nurse uses a correction fluid to correct a charting mistake.
- B. The nurse is shredding the worksheet at the end of the shift.
- C. The nurse circles an omitted medication time on the MAR.
- D. The nurse documents narcotic wastage with another nurse.
Correct Answer: A
Rationale: Using correction fluid obscures records, violating charting standards, requiring intervention. Shredding worksheets, circling omissions, or documenting wastage is appropriate.
The charge nurse is making assignments on an oncology floor. Which client should be assigned to the most experienced nurse?
- A. The client diagnosed with leukemia who has a hemoglobin of 6 g/dL.
- B. The client diagnosed with lung cancer with a pulse oximeter reading of 89%.
- C. The client diagnosed with colon cancer who needs the colostomy irrigated.
- D. The client diagnosed with Kaposi's sarcoma who is yelling at the staff.
Correct Answer: A
Rationale: Hemoglobin of 6 g/dL indicates severe anemia, requiring complex monitoring and transfusion, best handled by an experienced nurse. Hypoxia, colostomy care, or behavior are less acute.
The client is dying and wants to talk to the nurse about heaven. Which is the nurse's best nursing action?
- A. Make a referral to the chaplain to come to see the client.
- B. Tell the client that nurses are not allowed to discuss spiritual matters.
- C. Ask the client to describe heaven and hell.
- D. Allow the client to discuss the beliefs about heaven.
Correct Answer: D
Rationale: Allowing discussion of heaven respects client spirituality, per holistic care. Chaplain referral, prohibiting discussion, or prompting hell discussion is less supportive.
The client is in the psychiatric unit in a medical center. Which action by the psychiatric nurse is a violation of the client's legal and civil rights?
- A. The nurse tells the client civilian clothes can be worn on the unit.
- B. The nurse allows the client to have family visits during visiting hours.
- C. The nurse delivers unopened mail and packages to the client.
- D. The nurse listens to the client talking on the telephone to a friend.
Correct Answer: D
Rationale: Eavesdropping on a client’s phone call violates privacy rights, per civil liberties. Allowing clothes, visits, or mail respects client autonomy.
Which client would be most likely to complete an advance directive?
- A. A 55-year-old Caucasian person who is a bank president.
- B. A 34-year-old Asian licensed practical nurse.
- C. A 22-year-old Hispanic lawn care worker.
- D. A 65-year-old African American retired cook.
Correct Answer: D
Rationale: Older adults (e.g., 65-year-old) are more likely to complete ADs due to increased awareness of mortality and health issues, regardless of ethnicity or profession.