Med-Surg Success - Ch 18

42. The client receiving dialysis for end-stage renal disease wants to quit dialysis and die. Which ethical principle supports the client's right to die? 1. Autonomy. 2. Self-determination. 3. Beneficence. 4. Justice.

1. Autonomy implies the client has the right to make choices and decisions about his or her own care even if it may result in death or is not in agreement with the health-care team

59. The 6-year-old client diagnosed with cystic fibrosis (CF) needs a lung transplant. Which individual would be the best donor for the client? 1. The 20-year-old brother who does not have cystic fibrosis. 2. The 45-year-old father who carries the cystic fibrosis gene. 3. The 18-year-old who died in an MVA who matches on four (4) points. 4. The 5-year-old drowning victim who is a three (3)-point match.

1. Living donors are able to donate some organs. The kidneys, a portion of the liver, and a lung may be donated, and the donor will still have functioning organs. An identical twin is the best possible match. However, in the situation in this question, the identical twin would also have CF because the genes would be identical. The next best chance for a compatible match comes from a sibling with both parents in common

4. The client who is of the Jewish faith died during the night. The nurse notified the family, who do not want to come to the hospital. Which intervention should the nurse implement to address the family's behavior? 1. Take no further action because this is an accepted cultural practice. 2. Notify the hospital supervisor and report the situation immediately. 3. Call the local synagogue and request the rabbi go to the family's home. 4. Assume the family does not care about the client and follow hospital protocol.

1. Many of the Jewish faith do not believe in viewing or touching the dead body. The body is sent to the funeral home for burial within 24 hours, and a closed casket is preferred.

29. The client is being discharged from the hospital for intractable pain secondary to cancer and is prescribed morphine, a narcotic. Which statement indicates the client understands the discharge instructions? 1. "I will be sure to have my prescriptions filled before any holiday." 2. "There should not be a problem having the prescriptions filled anytime." 3. "If I run out of medications, I can call the HCP to phone in a prescription." 4. "There are no side effects to morphine I should be concerned about."

1. Narcotic medications require handwritten prescription forms (Drug Enforcement Agency rules) which must be filled within a limited time frame from the time the prescription is written. Many local pharmacies will not have the medication available or may not have it in the quantities needed. The client should anticipate the needs prior to any time when the HCP may not be available or the pharmacy may be closed.

46. Which entity mandates the registered nurse's behavior when practicing professional nursing? 1. The state's Nurse Practice Act. 2. Client's Bill of Rights. 3. The United States legislature. 4. American Nurses Association.

1. Nurse Practice Acts provide the laws which control the practice of nursing in each state. All states have Nurse Practice Acts.

52. The client has received a kidney transplant. Which assessment would warrant immediate intervention by the nurse? 1. Fever and decreased urine output. 2. Decreased creatinine and BUN levels. 3. Decreased serum potassium and calcium. 4. Bradycardia and hypotension.

1. Oliguria, fever, increasing edema, hypertension, and weight gain are signs of organ rejection.

12. The nurse is aware the Patient Self-Determination Act of 1991 requires the health-care facility to implement which action? 1. Make available an AD on admission to the facility. 2. Assist the client with legally completing a will. 3. Provide ethically and morally competent care to the client. 4. Discuss the importance of understanding consent forms.

1. The Patient Self-Determination Act of 1991 requires health-care facilities which receive Medicare or Medicaid funding to make ADs available to clients on admission into the facility

23. Which action by the primary nurse would require the unit manager to intervene? 1. The nurse uses a correction fluid to correct a charting mistake. 2. The nurse is shredding the worksheet at the end of the shift. 3. The nurse circles an omitted medication time on the MAR. 4. The nurse documents narcotic wastage with another nurse.

1. The client's chart is a legal document, and if a mistake occurs, it should be corrected by marking one line through the entry in such a way the entry can still be read in a court of law. Erasing, using a correction fluid, or obliterating the entry is illegal.

19. The hospice care nurse is planning the care of an elderly client diagnosed with end-stage renal disease. Which interventions should be included in the plan of care? Select all that apply. 1. Discuss financial concerns. 2. Assess any comorbid conditions. 3. Monitor increased visual or auditory abilities. 4. Note any spiritual distress. 5. Encourage euphoria at the time of death.

1. The elderly are frequently on fixed incomes, and financial concerns are important for the nurse to address. A social services referral may be needed. 2. The elderly may have many comorbid conditions, which affect the type and amount of medications the client can tolerate and the client's quality of life. 4. The client may feel some spiritual distress at the terminal diagnosis. Even if the client possesses a strong faith, the unknown can be frightening.

8. The HCP has notified the family of a client in a persistent vegetative state on a ventilator of the need to "pull the plug." The client does not have an AD or a durable power of attorney for health care, and the family does not want their loved one removed from the ventilator. Which action should the nurse implement? 1. Refer the case to the hospital ethics committee. 2. Tell the family they must do what the HCP orders. 3. Follow the HCP's order and "pull the plug." 4. Determine why the client did not complete an AD.

1. The ethics committee is composed of health-care workers and laypeople from the community to objectively review the situation and make a recommendation which is fair to both the client and healthcare system. The family has the right to be present and discuss their feelings.

16. The nurse is teaching a class on chronic pain to new graduates. Which information is most important for the nurse to discuss? 1. The nurse must believe the client's report of pain. 2. Clients in chronic pain may not show objective signs. 3. Alternate pain-control therapies are used for chronic pain. 4. Referral to a pain clinic may be necessary.

1. The most important information for a nurse caring for a client with acute or chronic pain is to believe the client. Pain is subjective, and the nurse should not be judgmental.

5. The hospice nurse is making the final visit to the wife whose husband died a little more than a year ago. The nurse realizes the husband's clothes are still in the closet and chest of drawers. Which action should the nurse implement first? 1. Discuss what the wife is going to do with the clothes. 2. Refer the wife to a grief recovery support group. 3. Do not take any action because this is normal grieving. 4. Remove the clothes from the house and dispose of them.

1. The nurse must first confront the wife about moving on through the grieving process. After one (1) year, the wife should be seriously thinking about what to do with her husband's belongings.

24. Which action should the nurse implement for the Chinese client's family who are requesting to light incense around the dying client? 1. Suggest the family bring potpourri instead of incense. 2. Tell the client the door must be shut at all times. 3. Inform the family the scent will make the client nauseated. 4. Explain fire code does not allow any burning in a hospital.

1. The nurse must support the client's culture. Potpourri provides the scent without having the burning incense, which is against fire code, and thus is a compromise which supports the client's culture.

9. Which interventions should the nurse implement at the time of a client's death? Select all that apply. 1. Allow gaps in the conversation at the client's bedside. 2. Avoid giving the family advice about how to grieve. 3. Tell the family the nurse understands their feelings. 4. Explain this is God's will to prevent further suffering. 5. Allow the family time with the body in private.

1. The nurse needs to be sensitive to the family, and simply being present to support the family emotionally is important; the nurse does not have to talk. 2. The nurse should avoid the impulse to give advice; each person grieves in his or her own way. 5. The family needs time for closure, and allowing the family to stay at the bedside is meeting the family's need to say good-bye.

21. The client is on the ventilator and has been declared brain dead. The spouse refuses to allow the ventilator to be discontinued. Which collaborative action by the nurse is most appropriate? 1. Discuss referral of the case to the ethics committee. 2. Pull the plug when the spouse is not in the room. 3. Ask the HCP to discuss the futile situation with the spouse. 4. Inform the spouse what is happening is cruel.

1. The nurse should discuss using the ethics committee with the HCP to assist the family in making the decision to terminate life support. Many families feel there may be a racial or financial reason the HCP wants to discontinue life support.

18. The nurse writes a client problem of "spiritual distress" for the client who is dying. Which statement is an appropriate goal? 1. The client will reconcile self and the higher power of his or her beliefs. 2. The client will be able to express anger at the terminal diagnosis. 3. The client will reconcile self to estranged members of the family. 4. The client will have a dignified and pain-free death.

1. The primary goal of spiritual care is to allow the client to be able to reconcile himself or herself with a higher being, maybe God. This goal is based on the belief that life comes from God, and to some degree for many people the process of living includes some separation from God. In the Western world, 95% of the people claim some belief in God

13. The spouse of a client dying from lung cancer states, "I don't understand this death rattle. She has not had anything to drink in days. Where is the fluid coming from?" Which is the hospice care nurse's best response? 1. "The body produces about two (2) teaspoons of fluid every minute on its own." 2. "Are you sure someone is not putting ice chips in her mouth?" 3. "There is no reason for this, but it does happen from time to time." 4. "I can administer a patch to her skin to dry up the secretions if you wish."

1. The respiratory tract cells produce liquid as a defense mechanism against bacteria and other invaders. About nine (9) mL a minute are produced. The "death rattle" can be disturbing to family members, and the nurse should intervene but not with suctioning, which will increase secretions and the need to suction more.

40. 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? 1. Notify the client's surgeon. 2. Document the information in the chart. 3. Contact the operating room staff. 4. Explain the procedure to the client.

1. The surgeon is responsible for explaining the surgical procedure to the client; therefore, the nurse should first notify the surgeon

58. The experienced medical-surgical nurse is being oriented to the transplant unit. Which client should the charge nurse assign to this nurse? 1. The client who donated a kidney to a relative three (3) days ago and will be discharged in the morning. 2. The client who had a liver transplantation three (3) days ago and was transferred from the intensive care unit two (2) hours ago. 3. The client who received a corneal transplant four (4) hours ago and has developed a cough and is vomiting. 4. The client who had a pancreas transplantation and has a fever, chills, and a blood glucose monitor reading of 342.

1. This client is ready for discharge and is presumably stable. The client donated the kidney and still has one functioning kidney. An experienced medical-surgical nurse could care for this client

11. The client has been declared brain dead and is an organ donor. The nurse is preparing the wife of the client to enter the room to say good-bye. Which information is most important for the nurse to discuss with the wife? 1. Inform the wife the client will still be on the ventilator. 2. Instruct the wife to only stay a few minutes at the bedside. 3. Tell the wife it is all right to talk to the client. 4. Allow another family member to go in with the wife.

1. This is the most important action because, when the wife walks in the room, the client's chest will be rising and falling, the monitor will show a heartbeat, and the client will be warm. Many family members do not realize this and think the client is still alive. The organs must be perfused until retrieved for organ donation

55. The nurse is caring for a client who received a kidney transplant from an unrelated cadaver donor. Which interventions should be included in the plan of care? Select all that apply. 1. Collect a urine culture every other day. 2. Prepare the client for dialysis three (3) times a week. 3. Monitor urine osmolality studies. 4. Monitor intake and output every shift. 5. Check abdominal dressing every four (4) hours.

1. Urine cultures are performed frequently because of the bacteriuria present in the early stages of transplantation. 2. A cadaver kidney may have undergone acute tubular necrosis and may not function for two (2) to three (3) weeks, during which time the client may experience anuria, oliguria, or polyuria and require dialysis.

The client tells the nurse, "Every time I come in the hospital you hand me one of these advance directives (AD). Why should I fill one of these out?" Which statement by the nurse is most appropriate? 1. "You must fill out this form because Medicare laws require it." 2. "An AD lets you participate in decisions about your health care." 3. "This paper will ensure no one can override your decisions." 4. "It is part of the hospital admission packet and I have to give it to you."

2. ADs allow the client to make personal health-care decisions about end-of-life issues, including cardiopulmonary resuscitation (CPR), ventilators, feeding tubes, and other issues concerning the client's death. TEST-TAKING HINT: The test taker could eliminate option "1" because the nurse cannot make the client do anything. The client has a right to say no. Option "3" is an absolute, and unless the test taker knows for sure this is correct information, the test taker should not select this option. Content - Medical: Category of Health Alteration - Patient Advocacy: Integrated Nursing Process - Implementation: Client Needs - Safe Effective Care Environment, Management of Care: Cognitive Level - Application.

22. The client has been in a persistent vegetative state for several years. The family, who have decided to withhold tube feedings because there is no hope of recovery, asks the nurse, "Will the death be painful?" Which intervention should the nurse implement? 1. Tell the family the death will be painful but the HCP can order medications. 2. Inform the family dehydration provides a type of natural euphoria. 3. Relate other cases where the clients have died in excruciating pain. 4. Ask the family why they are concerned because they want the client to die anyway.

2. Death from dehydration occurs when the client is unable to take in fluids. A natural euphoria occurs with dehydration. This is the body's way of allowing comfort at the time of death.

48. The nurse is discussing malpractice issues in an in-service class. Which situation is an example of malpractice? 1. The nurse fails to report a neighbor who is abusing his two children. 2. The nurse does not intervene in a client who has a BP of 80/50 and AP of 122. 3. The nurse is suspected of taking narcotics prescribed for a client. 4. The nurse falsifies vital signs in the client's medical records.

2. Malpractice is a failure to meet the standards of care which results in harm to or death of a client. Failing to heed warnings of shock is an example of malpractice.

28. The client diagnosed with cancer is experiencing severe pain. Which regimen would the nurse teach the client about to control the pain? 1. Nonsteroidal anti-inflammatory drugs (NSAIDs) around the clock with narcotics used for severe pain. 2. Morphine sustained release, a narcotic, routinely with a liquid morphine preparation for breakthrough pain. 3. Extra-Strength Tylenol, a nonnarcotic analgesic, plus therapy to learn alternative methods of pain control. 4. Demerol, an opioid narcotic, every six (6) hours orally with a suppository when the pain is not controlled.

2. Morphine is the drug of choice for cancer pain. There is no ceiling effect, it metabolizes without harmful byproducts, and it is relatively inexpensive. A sustained-release formulation, such as MS Contin, is administered every six (6) to eight (8) hours, and a liquid fast-acting form is administered sublingually for any pain which is not controlled.

18. The client diagnosed with cancer is unable to attain pain relief despite receiving large amounts of narcotic medications. Which intervention should be included in the plan of care? 1. Ask the HCP to increase the medication. 2. Assess for any spiritual distress. 3. Change the client's position every two (2) hours. 4. Turn on the radio to soothing music.

2. Pain has many components, and spiritual distress or psychosocial needs will affect the client's perception of pain; remember, assessment is the first step of the nursing process

19. The client diagnosed with chronic pain is laughing and joking with visitors. When the nurse asks the client to rate the pain on a 1-to-10 scale, the client rates the pain as 10. According to the pain scale, how would the nurse chart the client's pain? 1. The client's pain is between a zero (0) and two (2) on the faces scale. 2. The client's pain is a "10" on a 1-to-10 pain scale. 3. The client is unable to accurately rate the pain on a scale. 4. The client's pain is moderate on the pain scale. CHAPTER 18 END-OF-LIFE ISSUES 703 0 No hurt 0 1 Hurts little bit 2 2 Hurts little more 4 3 Hurts even more 6 4 Hurts whole lot 8 5 Hurts worst 10 0 No Pain Unbearable Pain Severe Pain Moderate Pain Mild Pain 1 2 3 4 5 6 7 8 9 10 Alternate coding

2. Pain is whatever the client says it is and occurs whenever the client says it does. Pain is a wholly subjective symptom, and the nurse should not question the client's perception of pain. The client's pain is a 10.

51. The client diagnosed with septicemia expired, and the family tells the nurse the client is an organ donor. Which intervention should the nurse implement? 1. Notify the organ and tissue organizations to make the retrieval. 2. Explain a systemic infection prevents the client from being a donor. 3. Call and notify the health-care provider of the family's request. 4. Take the body to the morgue until the organ bank makes a decision.

2. Septicemia is a systemic infection and will prevent the client from donating tissues or organs.

14. The nurse is discussing placing the client diagnosed with chronic obstructive pulmonary disease (COPD) in hospice care. Which prognosis must be determined to place the client in hospice care? 1. The client is doing well but could benefit from the added care by hospice. 2. The client has a life expectancy of six (6) months or less. 3. The client will live for about one (1) to two (2) more years. 4. The client has about eight (8) weeks to live and needs pain control.

2. The HCP must think that, without life-prolonging treatment, the client has a life expectancy of six (6) months or less. The client may continue receiving hospice care if the client lives longer.

57. The nurse and an unlicensed assistive personnel (UAP) are caring for clients on a postoperative transplant unit. Which task should the nurse delegate to the UAP? 1. Assess the hourly outputs of the client who is post-kidney transplantation. 2. Raise the head of the bed for a client who is post-liver transplantation. 3. Monitor the serum blood studies of a client who has rejected an organ. 4. Irrigate the nasogastric tube of the client who had a pancreas transplant.

2. The UAP can perform this function. There is no nursing judgment required

20. The nurse is orienting to a hospice organization. Which statement does not indicate a right of the terminal client? The right to: 1. Be treated with respect and dignity. 2. Have particulars of the death withheld. 3. Receive optimal and effective pain management. 4. Receive holistic and compassionate care.

2. The client has the right to discuss his or her feelings and direct his or her care. Withholding information would be lying to the client.

11. Which situation would cause the nurse to question the validity of an AD when caring for the elderly client? 1. The client's child insists the client make his or her own decisions. 2. The nurse observes the wife making the husband sign the AD. 3. A nurse encouraged the client to think about end-of-life decisions. 4. A friend witnesses the client's signature on the AD form.

2. This is coercion and is illegal when signing an AD. The AD must be signed by the client's own free will; an AD signed under duress may not be valid.

31. The male client who has made himself a do not resuscitate (DNR) order is in pain. The client's vital signs are P 88, R 8, and BP 108/70. Which intervention should be the nurse's priority action? 1. Refuse to give the medication because it could kill the client. 2. Administer the medication as ordered and assess for relief from pain. 3. Wait until the client' respirations improve and then administer the medication. 4. Notify the HCP the client is unstable and pain medication is being held.

2. The client is in pain. The American Nurses Association Code of Ethics states clients have the right to die as comfortably as possible even if the measures used to control the pain indirectly hasten the impending death. The Dying Client's Bill of Rights reiterates this position. The client should be allowed to die with dignity and with as much comfort as the nurse can provide.

36. The female client in the oncology clinic tells the nurse she has a great deal of pain but does not like to take pain medication. Which action should the nurse implement first? 1. Tell the client it is important for her to take her medication. 2. Find out how the client has been dealing with the pain. 3. Have the HCP tell the client to take the pain medications. 4. Instruct the client not to worry—the pain will resolve itself.

2. The nurse should assess the situation fully. The client may be afraid of becoming addicted or may have been using alternative forms of treatment, such as music therapy, distraction techniques, acupuncture, or guided imagery

8. The Hispanic client who has terminal cancer is requesting a curandero to come to the bedside. Which intervention should the nurse implement? 1. Tell the client it is against policy to allow faith healers. 2. Assist with planning the visit from the curandero. 3. Refer the client to the pastoral care department. 4. Determine the reason the client needs the curandero.

2. The nurse should support the client's culture as long as it is not contraindicated in the client's care. This client is terminal; therefore, allowing the curandero, who is a folk healer and religious person in the Hispanic culture, would be appropriate.

13. The intensive care nurse is caring for a deceased client who is an organ donor, and the organ donation team is in route to the hospital. Which statement would be an appropriate goal of treatment for the client? 1. The urinary output is 20 mL/hr via a Foley catheter. 2. The systolic blood pressure is greater than 90 mm Hg. 3. The pulse oximeter reading remains between 88% and 90%. 4. The telemetry shows the client in sinus tachycardia.

2. The systolic blood pressure must be maintained at this rate to keep the client's organs perfused until removal.

1. The 38-year-old client was brought to the emergency department with CPR in progress and expired 15 minutes after arrival. Which intervention should the nurse implement for postmortem care? 1. Do not allow significant others to see the body. 2. Do not remove any tubes from the body. 3. Prepare the body for the funeral home. 4. Send the client's clothing to the hospital laundry.

2. This death should be reported to the medical examiner because the death occurred less than 24 hours after hospital admission and an autopsy may be required. Therefore, the nurse must leave all tubes in place; the medical examiner will remove the tubes.

44. Which element is not necessary to prove nursing malpractice? 1. Breach of duty. 2. Identify the ethical issues. 3. Injury to the client. 4. Proximate cause.

2. This is one (1) of the four (4) steps in ethical decision making. It is not one (1) of the four (4) elements necessary to prove nursing malpractice.

14. The nurse is teaching a class on ethical principles in nursing. Which statement supports the definition of beneficence? 1. The duty to prevent or avoid doing harm. 2. The duty to actively do good for clients. 3. The duty to be faithful to commitments. 4. The duty to tell the truth to the clients.

2. This is the ethical principle of beneficence.

7. The client has just signed an AD at the bedside. Which intervention should the nurse implement first? 1. Notify the client's health-care provider about the AD. 2. Instruct the client to discuss the AD with significant others. 3. Place a copy of the advance directive in the client's chart. 4. Give the original advance directive to the client.

2. This is the most important intervention because the legality of the document is sometimes not honored if the family members disagree and demand other action. If the client's family is aware of the client's wishes, then the health-care team can support and honor the client's final wishes.

32. The charge nurse is making assignments on an oncology floor. Which client should be assigned to the most experienced nurse? 1. The client diagnosed with leukemia who has a hemoglobin of 6.0 g/dL. 2. The client diagnosed with lung cancer with a pulse oximeter reading of 89%. 3. The client diagnosed with colon cancer who needs the colostomy irrigated. 4. The client diagnosed with Kaposi's sarcoma who is yelling at the staff.

2. This represents an arterial blood gas of less than 60%; this client should be assigned to the most experienced nurse

37. The nurse is teaching an in-service on legal issues in nursing. Which situation is an example of battery, an intentional tort? 1. The nurse threatens the client who is refusing to take a hypnotic medication. 2. The nurse forcibly inserts a Foley catheter in a client who refused it. 3. The nurse tells the client a nasogastric tube insertion is not painful. 4. The nurse gives confidential information over the telephone.

2. When a mentally competent adult is forced to have a treatment he or she has refused, battery occurs.

30. The client diagnosed with intractable pain is receiving an IV constant infusion of morphine, a narcotic opioid. The concentration is 50 mg of morphine in 250 mL of normal saline. The IV is infusing at 10 mL/hr. The client has required bolus administration of two (2) mg IVP × two (2) during the 12-hour shift. How much morphine has the client received during the shift? _________

28 mg of morphine. First, determine how many milligrams of morphine are in each milliliter of saline: 50 ÷ 250 mL = 0.2 mg/mL Then determine how many milliliters are given in a shift: 10 mL/hr × 12 hour = 120 mL infused 1 shift = 120 mL infused If each milliliter contains 0.2 milligram of morphine, then 0.2 mg × 120 mL = 24 mg by constant infusion Then determine the amount given IVP: 2 × 2 = 4 mg given IVP Finally, add the bolus amount to the amount constantly infused: 24 + 4 = 28 mg

6. The nurse is giving an in-service on end-of life-issues. Which activity should the nurse encourage the participants to perform? 1. Discuss with another participant the death of a client. 2. Review the hospital postmortem care policy. 3. Justify not putting the client in a shroud after dying. 4. Write down their own beliefs about death and dying.

4. Many nurses are reluctant to discuss death openly with their clients because of their own anxieties about death. Therefore, coming face to face with the nurse's own mortality will address the fear of death.

10. The male client requested a DNR per the AD, and the HCP wrote the order. The client's death is imminent and the client's wife tells the nurse, "Help him please. Do something. I am not ready to let him go." Which action should the nurse take? 1. Ask the wife if she would like to revoke her husband's AD. 2. Leave the wife at the bedside and notify the hospital chaplain. 3. Sit with the wife at the bedside and encourage her to say good-bye. 4. Request the client to tell the wife he is ready to die, and don't do anything.

3. At the time of death, loved ones become scared and find it difficult to say good-bye. The nurse should support the client's decision and acknowledge the wife's psychological state. Research states hearing is the last sense to go, and talking to the dying client is therapeutic for the client and the family.

16. The hospice care nurse is conducting a spiritual care assessment. Which statement is the scientific rationale for this intervention? 1. The client will ask all of his or her spiritual questions and get answers. 2. The nurse is able to explain to the client how death will affect the spirit. 3. Spirituality provides a sense of meaning and purpose for many clients. 4. The nurse is the expert when assisting the client with spiritual matters.

3. Clients facing death may wish to find meaning and purpose in life through a higher power. This gives the clients hope, even if the life on earth will be temporary

53. The client received a liver transplant and is preparing for discharge. Which discharge instruction should the nurse teach? 1. The immune-suppressant drugs must be tapered off when discontinuing them. 2. There may be slight foul-smelling drainage on the dressing for a few days. 3. Notify the HCP immediately if a cough or fever develops. 4. The skin will turn yellow from the anti-rejection drugs.

3. Clients should be taught to notify the HCP immediately of any signs of an infection. The immune-suppressant drugs will mask the sign of an infection and superinfections can develop

2. The primary nurse caring for the client who died is crying with the family at the bedside. Which action should the charge nurse implement? 1. Request the primary nurse to come out in the hall. 2. Refer the nurse to the employee assistance program. 3. Allow the nurse and family this time to grieve. 4. Ask the chaplain to relieve the nurse at the bedside.

3. Crying was once considered unprofessional, but today it is recognized as simply an expression of empathy and caring

10. The male client asks the nurse, "Should I designate my wife as durable power of attorney for health care?" Which statement would be the nurse's best response? 1. "Yes, she should be because she is your next of kin." 2. "Most people don't allow their spouse to do this." 3. "Will your wife be able to support your wishes?" 4. "Your children are probably the best ones for the job."

3. No matter who the client selects as the power of attorney, the most important aspect is to make sure the person, whether it be the wife, child, or friend, will honor the client's wishes no matter what happens.

17. The client with chronic low back pain is having trouble sleeping at night. Which nonpharmacological therapy should the nurse teach the client? 1. Acupuncture. 2. Massage therapy. 3. Herbal remedies. 4. Progressive relaxation techniques.

4. Progressive relaxation techniques involve visualizing a specific muscle group and mentally relaxing each muscle; this can be taught to the client, and it will allow the client to relax, which will foster sleep.

26. The client had a mastectomy and lymph node dissection three (3) years ago and has experienced postmastectomy pain (PMP) since. Which intervention should the nurse implement? 1. Have the client see a psychologist because the pain is not real. 2. Tell the client the pain is the cancer coming back. 3. Refer the client to a physical therapist to prevent a frozen shoulder. 4. Discuss changing the client to a more potent narcotic medication.

3. PMP is characterized as a constriction accompanied by a burning sensation or prickling in the chest wall, axilla, or posterior arm resulting from movement of the arm. Because of this, the client limits movement of the arm and the shoulder becomes frozen.

27. The male client diagnosed with chronic pain since a construction accident which broke several vertebrae tells the nurse he has been referred to a pain clinic and asks, "What good will it do? I will never be free of this pain." Which statement is the nurse's best response? 1. "Are you afraid of the pain never going away?" 2. "The pain clinic will give you medication to cure the pain." 3. "Pain clinics work to help you achieve relief from pain." 4. "I am not sure. You should discuss this with your HCP."

3. Pain clinics use a variety of methods to help the client to achieve relief from pain. Some measures include guided imagery, transcutaneous electrical nerve stimulation (TENS) units, nerve block surgery or injections, or medications.

15. Which action by the unlicensed assistive personnel (UAP) would warrant immediate intervention by the nurse? 1. The UAP is holding the phone to the ear of a client who is a quadriplegic. 2. The UAP refuses to discuss the client's condition with the visitor in the room. 3. The UAP put a vest restraint on an elderly client found wandering in the hall. 4. The UAP is assisting the client with arthritis to open up personal mail.

3. Restraints are not allowed unless there is a health-care provider's order with documentation by the nurse of the client being a danger to himself or others. The UAP's putting the client in restraints warrants immediate intervention because it is battery

56. The client is three (3) hours post-heart transplantation. Which data would support a complication of this procedure? 1. The client has nausea after taking the oral anti-rejection medication. 2. The client has difficulty coming off the heart-lung bypass machine. 3. The client has saturated three (3) ABD dressing pads in one (1) hour. 4. The client complains of pain at a "6" on a 1-to-10 scale.

3. Saturating three (3) dressing pads in one (1) hour would indicate hemorrhage.

7. 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? 1. Bring the crash cart to the bedside. 2. Apply oxygen via nasal cannula. 3. Notify a priest for last rites. 4. Turn the bed to face the sunset.

3. The Catholic religion requires last rites be performed immediately before or after death

25. The nurse is caring for the client who has active tuberculosis of the lungs. The client does not have a DNR order. The client experiences a cardiac arrest, and there is no resuscitation mask at the bedside. The nurse waits for the crash cart before beginning resuscitation. According to the ANA Code of Ethics for Nurses (see below), which disciplinary action should be taken against the nurse? 1. Report the action to the State Board of Nurse Examiners. 2. The nurse should be terminated for failure to perform duties. 3. No disciplinary action should be taken against the nurse. 4. Refer the nurse to the American Nurses Association.

3. The Code states, "The nurse owes the same duty to self as to others, including the responsibility to preserve integrity and safety." Therefore, if the nurse realizes he or she could contract TB if unprotected mouth-to-mouth resuscitation is performed, then not doing this action does not violate the Code of Ethics.

34. The client diagnosed with chronic back pain is being placed on a transcutaneous electrical nerve stimulation (TENS) unit. Which information should the nurse teach? 1. The TENS unit will deaden the nerve endings, and the client will not feel pain. 2. The TENS unit could cause paralysis if the client gets the unit wet. 3. The TENS unit stimulates the nerves in the area, blocking the pain sensation. 4. The TENS unit should be left on for an hour, and then taken off for an hour.

3. The TENS unit works on the gate control theory of pain control and works by flooding the area with stimulation and blocking the pain impulses from reaching the brain.

50. The nurse is discussing the HCP's recommendation for removal of life support with the client's family. Which information concerning brain death should the nurse teach the family? 1. Positive waves on the electroencephalogram (EEG) mean the brain is dead and any further treatment is futile. 2. When putting cold water in the ear, if the client reacts by pulling away, this demonstrates brain death. 3. Tests will be done to determine if any brain activity exists before the machines are turned off. 4. Although the blood flow studies don't indicate activity, the client can still come out of the coma.

3. The Uniform Determination of Brain Death Act states brain death is determined by accepted medical standards which indicate irreversible loss of all brain function. Cerebral blood flow studies, EEG, and oculovestibular and oculocephalic tests may be done.

6. The client with an AD tells the nurse, "I have changed my mind about my AD. I really want everything possible done if I am near death since I have a grandchild." Which action should the nurse implement? 1. Notify the health information systems department to talk to the client. 2. Remove the AD from the client's chart and shred the document. 3. Inform the client he or she has the right to revoke the AD at any time. 4. Explain this document cannot be changed once it is signed.

3. The client must be informed the AD can be rescinded or revoked at any time for any reason verbally, in writing, or by destroying his or her own AD. The nurse cannot destroy the client's AD, but the client can destroy his or her own.

3. In which client situation would the AD be consulted and used in decision making? 1. The client diagnosed with Guillain-Barré who is on a ventilator. 2. The client with a C6 spinal cord injury in the rehabilitation unit. 3. The client in end-stage renal disease who is in a comatose state. 4. The client diagnosed with cancer who has Down syndrome.

3. The client must have lost decisionmaking capacity as a result of a condition which is not reversible or must be in a condition specified under state law, such as a terminal, persistent vegetative state; an irreversible coma; or as specified in the AD.

23. The family is dealing with the imminent death of the client. Which information is most important for the nurse to discuss when planning interventions for the grieving process? 1. How angry are the family members about the death? 2. Which family member will be making decisions? 3. What previous coping skills have been used? 4. What type of funeral service has been planned?

3. The nurse should assess previous coping skills used by the family and build on those to assist the family in dealing with their loss. Coping mechanisms are learned behaviors and should be supported if they are healthy behaviors. If the client and family use unhealthy coping behaviors, then the nurse should attempt to guide the family to a counselor or support group.

39. The family has requested a client with terminal cancer not be told of the diagnosis. The client tells the nurse, "I think something is really wrong with me, but the doctor says everything is all right. Do you know if there is something wrong with me?" Which response by the nurse would support the ethical principle of veracity? 1. "I think you should talk to your doctor about your concerns." 2. "What makes you think something is really wrong?" 3. "Your family has requested you not be told your diagnosis." 4. "The doctor would never tell you incorrect information."

3. The principle of veracity is the duty to tell the truth. This response is telling the client the truth.

54. The pregnant client asks the nurse about banking the cord blood. Which information should the nurse teach the client? 1. The procedure involves a lot of pain with a very poor result. 2. The client must deliver at a large public hospital to do this. 3. The client will be charged a yearly storage fee on the cells. 4. The stem cells can be stored for about four (4) years before they ruin.

3. There is an initial fee to process the stem cells and a yearly fee to maintain the stored stem cells until needed. Stem cells may be used by the infant in case of a devastating illness or can be donated at the discretion of the owner.

35. The nurse is caring for clients on a medical floor. Which client should the nurse assess first after the shift report? 1. The client with arterial blood gases of pH 7.36, PaCO2 40, HCO3 26, PaO2 90. 2. The client with vital signs of T 99˚F, P 101, R 28, and BP 120/80. 3. The client complaining of pain at a "10" on a 1-to-10 scale who can't localize it. 4. The client who is postappendectomy with pain at a "3" on a 1-to-10 scale.

3. This is typical of clients with chronic pain. They cannot localize the pain and frequently describe the pain as always being there, as disturbing rest, and as demoralizing. This client should be seen, and appropriate pain-control measures should be taken

47. The nurse must be knowledgeable of ethical principles. Which is an example of the ethical principle of justice? 1. The nurse administers a placebo, and the client asks if it will help the pain. 2. The nurse accepts a work assignment in an area in which he or she is not experienced. 3. The nurse refuses to tell a family member the client has a positive HIV test. 4. The nurse provides an indigent client with safe and appropriate nursing care.

4. Justice involves the duty to treat all clients fairly, without regard to age, socioeconomic status, or any other variables. Providing safe and appropriate nursing care to all clients is an example of justice.

12. Which client would the nurse exclude from being a potential organ/tissue donor? 1. The 60-year-old female client with an inoperable primary brain tumor. 2. The 45-year-old female client with a subarachnoid hemorrhage. 3. The 22-year-old male client who has been in a motor-vehicle accident. 4. The 36-year-male client recently released from prison.

4. A male client who has been in prison is at risk for being HIV positive, which excludes him from being an organ/ tissue donor.

17. The nurse is caring for a dying client and the family. The male client is Muslim. Which intervention should the female nurse implement at the time of death? 1. Allow the wife to stay in the room during postmortem care. 2. Call the client's iman to perform last rites when the client dies. 3. Place incense around the bed, but do not allow anyone to light it. 4. Do not touch the body, and have the male family members perform care.

4. Females, including the spouse, are not allowed to touch a male's body after death. The nurse should respect this and allow the male members of the family or mosque to perform postmortem care.

38. Which act protects the nurse against a malpractice claim when the nurse stops at a motor-vehicle accident and renders emergency care? 1. The Health Insurance Portability and Accountability Act. 2. The State Nurse Practice Act. 3. The Emergency Rendering Aid Act. 4. The Good Samaritan Act.

4. The Good Samaritan Act protects health-care practitioners against malpractice claims for care provided in emergency situations.

3. 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? 1. "The federal government mandates this form must be completed by you." 2. "This will make sure your family does what you want them to do." 3. "Don't you think it is important to let everyone know your final wishes?" 4. "Because of technology, there are many options for end-of-life care."

4. Technology now allows for the body to maintain life functions indefinitely in some futile situations. ADs allow clients to make decisions which hopefully will be honored at the time of their death.

43. Which document is the best professional source to provide direction for a nurse when addressing ethical issues and behavior? 1. The Hippocratic Oath. 2. The Nuremberg Code. 3. Home Health Care Bill of Rights. 4. ANA Code of Ethics.

4. The American Nurses Association (ANA) Code of Ethics outlines to society the values, concerns, and goals of the nursing profession. The code provides direction for ethical decisions and behavior by emphasizing the obligations and responsibilities which are entailed in the nurse-client relationship.

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? 1. Advance directives must be notarized by a notary public. 2. The client must use an attorney to complete the advanced directive. 3. Once the DNR is written, it can be used for every hospital admission. 4. The health-care provider must write the DNR order in the client's chart

4. The HCP writes the DNR order in the client's chart, and the client completes the AD. TEST-TAKING HINT: Options "1" and "2" involve other legal entities outside the health-care arena, which would make the test taker eliminate them. Content - Medical: Category of Health Alteration - Patient Advocacy: Integrated Nursing Process - Planning: Client Needs - Safe Effective Care Environment, Management of Care: Cognitive Level - Synthesis.

20. 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? 1. "It is wonderful you want to be an organ donor. Let's discuss this." 2. "You can donate any organ in your body, except the pancreas." 3. "You have to donate your body to science to be an organ donor." 4. "You cannot donate any organs, but you can donate some tissues."

4. The client can donate corneas, skin, and some joints, but organ donation from clients with type 2 diabetes mellitus usually is not allowed.

24. The client who is terminally ill called the significant others to the room and said good-bye, then dismissed them and now lies quietly and refuses to eat. The nurse understands the client is in what stage of the grieving process? 1. Denial. 2. Anger. 3. Bargaining. 4. Acceptance.

4. The client has accepted the imminent death and is withdrawing from the significant others.

25. The nurse is assessing a client diagnosed with chronic pain. Which characteristics would the nurse observe? 1. The client's blood pressure is elevated. 2. The client has rapid shallow respirations. 3. The client has facial grimacing. 4. The client is lying quietly in bed.

4. The client in chronic pain will have adapted to living with the pain, and lying quietly may be the best way for the client to limit the feeling of pain.

15. The client diagnosed with end-stage congestive heart failure and type 2 diabetes is receiving hospice care. Which action by the nurse demonstrates an understanding of the client's condition? 1. The nurse monitors the blood glucose four (4) times a day. 2. The nurse keeps the client on a strict fluid restriction. 3. The nurse limits the visitors the client can receive. 4. The nurse brings the client a small piece of cake.

4. The client may have diabetes, but the client is also terminal, and allowing some food for pleasure is understanding of the client's life expectancy

9. The client asks the nurse, "When will the durable power of attorney for health care take effect?" On which scientific rationale would the nurse base the response? 1. It goes into effect when the client needs someone to make financial decisions. 2. It will be effective when the client is under general anesthesia during surgery. 3. The client must say it is all right for it to become effective and enforced. 4. It becomes valid only when the clients cannot make their own decisions.

4. The client must have lost decisionmaking capacity as a result of a condition which is not reversible or must be in a condition which is specified under state law, such as a terminal, persistent vegetative state; an irreversible coma; or as specified in the AD.

60. Which tissue or organ can be repeatedly donated to clients needing a transplant? 1. Skin. 2. Bones. 3. Kidneys. 4. Bone marrow

4. The human body reproduces bone marrow daily. There is a bone marrow registry for participants willing to undergo the procedure to donate to clients when a match is found.

45. The nurse is caring for a client who is confused and fell trying to get out of bed. There is no family at the client's bedside. Which action should the nurse implement first? 1. Contact a family member to come and stay with the client. 2. Administer a sedative medication to the client. 3. Place the client in a chair with a sheet tied around him or her. 4. Notify the health-care provider to obtain a restraint order.

4. The nurse must notify the health-care provider before putting the client in restraints. Restraints are used in an emergency situation and for a limited time, and must be for the protection of the client.

33. The nurse and an unlicensed assistive personnel (UAP) are caring for a group of clients in a pain clinic. Which intervention would be inappropriate to delegate to the UAP? 1. Assist the client diagnosed with intractable pain to the bathroom. 2. Elevate the head of the bed for a client diagnosed with back pain. 3. Perform passive range of motion for a client who is bedfast. 4. Monitor the potassium levels on a client about to receive medication.

4. The nurse should monitor any laboratory work needed to administer a medication safely.

4. The nurse is moving to another state which is part of the multistate licensure compact. Which information regarding ADs should the nurse be aware of when practicing nursing in other states? 1. The laws regarding ADs are the same in all the states. 2. Advance directives can be transferred from state to state. 3. A significant other can sign a loved one's advance directive. 4. Advance directives are state regulated, not federally regulated.

4. The state determines the definition of terms and requirements for an AD; individual states are responsible for specific legal requirements for ADs.

22. Which intervention should the nurse implement to provide culturally sensitive health care to the European-American Caucasian elderly client who is terminal? 1. Discuss health-care issues with the oldest male child. 2. Determine if the client will be cremated or have an earth burial. 3. Do not talk about death and dying in front of the client. 4. Encourage the client's autonomy and answer questions truthfully.

4. The western Caucasian society values autonomy and truth telling in individual decision making

49. The mother of a 20-year-old African American male client receiving dialysis asks the nurse, "My son has been on the transplant list longer than that white woman. Why did she get the kidney?" Which statement is the nurse's best response? 1. "The woman was famous, and so more people will donate organs now." 2. "I understand you are upset your son is ill. Would you like to talk?" 3. "No one knows who gets an organ. You just have to wait and pray." 4. "The tissues must match or the body will reject the kidney and it will be wasted."

4. There are 27 known human leukocyte antigens (HLAs). HLAs have become the principal histocompatibility system used to match donors and recipients. The greater the number of matches, the less likely the client will reject the organ. Different races have different HLAs.

41. 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? 1. The nurse tells the client civilian clothes can be worn on the unit. 2. The nurse allows the client to have family visits during visiting hours. 3. The nurse delivers unopened mail and packages to the client. 4. The nurse listens to the client talking on the telephone to a friend.

4. This is a violation of the client's rights. The client has a right to have reasonable access to a telephone and the opportunity to have private conversations by telephone.

21. The client with multiple sclerosis who is becoming very debilitated tells the home health nurse the Hemlock Society sent information on euthanasia. Which question should the nurse ask the client? 1. "Why did you get in touch with the Hemlock Society?" 2. "Did you know this is an illegal organization?" 3. "Who do you know who has committed suicide?" 4. "What religious beliefs do you practice?"

4. This question must be asked because Judeo-Christian belief supports the view that suicide is a violation of natural law and the laws of God. The tenets of the Hemlock Society are in direct opposition to Judeo-Christian beliefs. If the client is agnostic, then this organization may be helpful to the client.

5. Which client would be most likely to complete an advance directive? 1. A 55-year-old Caucasian person who is a bank president. 2. A 34-year-old Asian licensed practical nurse. 3. A 22-year-old Hispanic lawn care worker. 4. A 65-year-old African American retired cook.

5. 1. ADs are more frequently completed by white, middle- to upper-class individuals.