Chapter 13: Palliative and End-of-Life Care

1. 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." Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 668). F.A. Davis Company. Kindle Edition.

1. 1. Advance directives (AD) are not legally required. It is a standard of the Joint Commission, and any facility which accepts federal funds must ask and offer the AD. 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. 3. This is not a legal document guaranteed to stand up in a court of law; therefore, the client should make sure all family members know the client's wishes. 4. It is part of the hospital admission requirements, but it is not the reason why the client should complete an AD. 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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 676). F.A. Davis Company. Kindle Edition. 2

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 692). F.A. Davis Company. Kindle Edition.

1. 1. There is no reason the family members should not be able to see the client; this is important to allow the significant others closure. 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. 3. This is a medical examiner case, and the nurse should not prepare the body by removing tubes or washing the body prior to taking the client to a funeral home. 4. The client's clothing should be given to the family or to the police if foul play is suspected. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 696). F.A. Davis Company. Kindle Edition. 2

1. According to the World Health Organization, palliative care is an approach that improves quality of life for patients and their families who face problems associated with life-threatening illnesses. From the list below, identify the specific goals of palliative care (select all that apply). a. Regard dying as a normal process. b. Minimize the financial burden on the family. c. Provide relief from symptoms, including pain. d. Affirm life and neither hasten nor postpone death. e. Prolong the patient's life with aggressive new therapies. f. Support holistic patient care and enhance quality of life. g. Offer support to patients to live as actively as possible until death. h. Assist the patient and family to identify and access pastoral care services. i. Offer support to the family during the patient's illness and their own bereavement. Lewis, Sharon L.; Lewis, Sharon L.; Bucher, Linda; Bucher, Linda; Dirksen, Shannon

1. a, c, d, f, g, i. Table 10-1 lists the goals of palliative care. Overall, goals of palliative care are to prevent and relieve suffering and to improve the quality of life for the patient. Lewis, Sharon L.; Lewis, Sharon L.; Bucher, Linda; Bucher, Linda; Dirksen, Shannon Ruff; Dirksen, Shannon Ruff. Study Guide for Medical-Surgical Nursing - E-Book (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 328). Elsevier Health Sciences. Kindle Edition.

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 693). F.A. Davis Company. Kindle Edition.

12. 1. Primary brain tumors rarely metastasize outside the skull, and this client can be a donor; cancers other than primary brain tumors prevent organ/tissue donation. 2. This is an excellent potential donor because all other organs are probably healthy. 3. This is an excellent candidate because this is a young person with a traumatic death, not a chronic illness. 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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 698). F.A. Davis Company. Kindle Edition. 4

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 669). F.A. Davis Company. Kindle Edition.

10. 1. Only the client can revoke the AD. 2. The wife should not be left alone, and the hospital chaplain may not be available for the client and his wife. 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. 4. The client is dying and should not be asked to exert himself for his wishes to be carried out. TEST-TAKING HINT: Logic would suggest option "4" is not a viable answer. Leaving a grieving spouse would not be appropriate in any situation; therefore, the test taker should eliminate option "2." Option "1" denies the client's autonomy and is not an ethical or a legal choice. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 678). F.A. Davis Company. Kindle Edition. 3

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." Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 693). F.A. Davis Company. Kindle Edition.

10. 1. The client can designate anyone he wishes to be the durable power of attorney. 2. This is not true; many spouses are designated as the durable power of attorney for health care. 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. 4. The children must be at least 18 years old and willing to honor the client's wishes. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 697). F.A. Davis Company. Kindle Edition. 3

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 669). F.A. Davis Company. Kindle Edition.

11. 1. This is appropriate for completing an AD and would not make the nurse question the validity of the AD. 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. 3. The nurse encouraging the client to think about ADs is an excellent intervention and would not make the AD invalid. 4. A friend can sign the AD as a witness; this would not cause the nurse to question its validity. TEST-TAKING HINT: This is an "except" question. The test taker could ask, "Which situation is valid for an AD?" Remember, three answers are valid information for the AD and only one is not. The test taker should read all answer options and not jump to conclusions. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 678). F.A. Davis Company. Kindle Edition. 2

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 693). F.A. Davis Company. Kindle Edition.

11. 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. 2. The wife should be encouraged to stay a short time and leave the facility before the client is taken to the operating room, but it is not the most important intervention. 3. It is all right for the wife to talk to the client, but because the client is brain dead and cannot hear her, it is not the most important intervention. 4. It is all right for another family member to go into the room, but it is not the most important intervention. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 697). F.A. Davis Company. Kindle Edition. 1

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 669). F.A. Davis Company. Kindle Edition.

12. 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. 2. This act is not concerned with completing a legal will. 3. Client care is not based on this act. 4. Consent forms are legal documents, which are not discussed in this act. TEST-TAKING HINT: The test taker should examine the word "self-determination" in the stem of the question, which matches the advance directive in option "1." The words "legally," "ethically," and "morally" in options "2" and "3" apply to the nurse in the healthcare setting, not the client. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 678). F.A. Davis Company. Kindle Edition. 1

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." Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 669). F.A. Davis Company. Kindle Edition.

13. 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. 2. This is a natural physical phenomenon and should be addressed. 3. There is an explanation. 4. The scopolamine patch applied to the skin helps to limit the secretions, but this does not answer the question. TEST-TAKING HINT: The test taker could eliminate option "3" because it states there is no reason, option "4" because it does not answer the question, and option "2" because it is attempting to fix blame. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 678). F.A. Davis Company. Kindle Edition. 1

13. The intensive care nurse is caring for a deceased client who is an organ donor, and the organ donation team is en 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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 693). F.A. Davis Company. Kindle Edition.

13. 1. The urinary output should be at least 30 mL/hr. 2. The systolic blood pressure must be maintained at this rate to keep the client's organs perfused until removal. 3. The pulse oximeter should be greater than 93%. 4. The client's heart must be beating, but it can be normal sinus rhythm or even sinus bradycardia. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 698). F.A. Davis Company. Kindle Edition. 2

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 669). F.A. Davis Company. Kindle Edition.

14. 1. Hospice care does not assume care of a client with a prognosis of more than six (6) months and who is doing well. 2. The HCP must think that, without lifeprolonging 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. 3. The client may live this long, but the HCP must think life expectancy is much shorter. 4. Hospice will attempt to manage symptoms of pain, nausea, and any other discomfort the client is experiencing, but the life expectancy is six (6) months. TEST-TAKING HINT: This is a knowledgebased question requiring an understanding of hospice. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 679). F.A. Davis Company. Kindle Edition. 2

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 693). F.A. Davis Company. Kindle Edition.

14. 1. This is the ethical principle of nonmalfeasance. 2. This is the ethical principle of beneficence. 3. This is the ethical principle of fidelity. 4. This is the ethical principle of veracity. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 698). F.A. Davis Company. Kindle Edition. 2

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 693). F.A. Davis Company. Kindle Edition.

15. 1. The client has a right to private phone conversations but, because the client is a quadriplegic, holding the phone to the ear does not require immediate intervention. 2. This is the appropriate action for the UAP and should be praised. 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. 4. The client has a right to send and receive mail, and the UAP is helping the client open the mail; therefore, this does not require immediate intervention. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 698). F.A. Davis Company. Kindle Edition. 3

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 669). F.A. Davis Company. Kindle Edition.

15. 1. This would be basic care, but it does not indicate the nurse is aware of the client's terminal prognosis. 2. This does not indicate an understanding of the client's terminal status. 3. The nurse should encourage visitors. There is not much time left for making memories, which will assist those left behind in dealing with the loss and allow the client time to say good-bye. 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. TEST-TAKING HINT: This question requires the test taker to look not only at the disease processes but also at the descriptive words "end-stage" and "hospice" and ask, "What do these descriptors mean to the disease process?" Not limiting the client in small ways indicates the nurse is aware the client has a limited time to live. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 679). F.A. Davis Company. Kindle Edition. 4

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 693). F.A. Davis Company. Kindle Edition.

16. 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. 2. This is a true statement because the client's sympathetic nervous system cannot remain in a continual state of readiness. This results in no objective data to support the pain and a normal pulse and blood pressure. However, it is not the most important information a new graduate should know. 3. Transcutaneous electrical nerve stimulation (TENS), distraction, imagery, acupuncture, and acupressure are all alternate pain therapies which may be used for chronic pain, but it is not the most important information the new graduate should know. 4. Pain clinics treat clients with chronic pain, but it is not the most important information a new graduate should know. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 698). F.A. Davis Company. Kindle Edition.

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 669). F.A. Davis Company. Kindle Edition.

16. 1. The nurse is not able to provide all spiritual answers to the client. 2. The nurse can explain physical aspects of death, but no one is able to tell the client with absolute knowledge what will happen to the soul or spirit at death. The beliefs of the client may differ greatly from those of the nurse. 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. 4. The nurse is not the expert but should be comfortable with his or her own beliefs to be able to allow the client to discuss personal beliefs and hopes. The experts would be chaplains and spiritual advisers from the client's faith. TEST-TAKING HINT: The test taker should recognize the nurse's expertise is not in the spiritual realm, although the nurse is frequently the one called on to perform the assessment and refer to the appropriate person. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 679). F.A. Davis Company. Kindle Edition. 3

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 693). F.A. Davis Company. Kindle Edition.

17. 1. Acupuncture is an alternative therapy, but a nurse cannot teach it and the client cannot do this to himself or herself. 2. A client cannot perform massage therapy on himself or herself. 3. The nurse should not prescribe herbal remedies. 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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 698). F.A. Davis Company. Kindle Edition. 4

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 imam 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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 670). F.A. Davis Company. Kindle Edition.

17. 1. No female is allowed to perform the postmortem care on a male Muslim client; this should be performed by a man. 2. Last rites are performed by a Catholic priest, not a Muslim imam. 3. Hindus use incense to pray, but Muslims do not. 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. TEST-TAKING HINT: The question is requiring culturally sensitive knowledge. The test taker must be aware of the different beliefs of the clients being cared for. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 679). F.A. Davis Company. Kindle Edition. 4

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 694). F.A. Davis Company. Kindle Edition.

18. 1. The client is already receiving large amounts of medication. The nurse should assess for other causes of pain. 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. 3. Usually clients will naturally assume the most comfortable position, and forcing them to move may increase their pain. 4. The client may or may not like this type of music, but it would not be the first intervention. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 699). F.A. Davis Company. Kindle Edition. 2

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 670). F.A. Davis Company. Kindle Edition.

18. 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. 2. This could be a goal for a diagnosis of anger, but it does not recognize the spiritual aspect of the client. 3. This would be a goal for altered family functioning. 4. This is the physiological goal for any client who is dying, but it is not a goal for spiritual distress. TEST-TAKING HINT: The identified problem is "spiritual distress," and the goal must have information which addresses the spiritual. This would eliminate option "4." Personal relationships with family members (option "3") could also be eliminated. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 680). F.A. Davis Company. Kindle Edition. 1

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 FACES® pain scale, how would the nurse chart the client's pain (See figure below)? 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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 694). F.A. Davis Company. Kindle Edition.

19. 1. The Faces pain scale was devised to help children identify pain when they are unable to understand the concept of numbers. The nurse can use this pain scale when caring for adults who are unable to use the 1-to-10 numerical scale. This client rated the pain at a 10. 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. 3. The client did rate the pain on the pain scale. Laughing and talking with visitors may occur with excruciating chronic pain. The client in chronic pain must learn to adapt to pain and try to live as normal a life as possible. 4. The client rated the pain at a 10. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 699). F.A. Davis Company. Kindle Edition. 2

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 670). F.A. Davis Company. Kindle Edition.

19. 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. 3. Visual and auditory senses decrease with age; they do not increase. 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. 5. A type of euphoria may accompany dehydration prior to death. This is a natural physiological occurrence the nurse should recognize, but it is not an intervention the nurse can implement. TEST-TAKING HINT: The test taker can decide on three (3) of the answer options based on the descriptive word "elderly." Option "5" is not a nursing intervention. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 680). F.A. Davis Company. Kindle Edition. 1,2,4

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 692). F.A. Davis Company. Kindle Edition.

2. 1. The nurse is providing care for the family and should not have to leave the bedside. 2. An employee assistance program is available at many facilities for counseling employees who are having psychosocial issues, but this nurse is being humane. 3. Crying was once considered unprofessional, but today it is recognized as simply an expression of empathy and caring. 4. The chaplain may come to the client's room and offer support but should not relieve the nurse who has developed a therapeutic nurse- client relationship with the client. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 696). F.A. Davis Company. Kindle Edition. 3

2. 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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 668). F.A. Davis Company. Kindle Edition.

2. 1. This is not true; someone who is not family or directly involved in the client's care must witness the AD, but the document does not have to be notarized. 2. This form can be filled out without the use of an attorney; copies of an AD can be obtained at hospitals or online from various sources. 3. The DNR order must be written on each admission. 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 healthcare arena, which would make the test taker eliminate them. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 676). F.A. Davis Company. Kindle Edition. 4

3. List the two criteria for admission to a hospice program. a. b. Lewis, Sharon L.; Lewis, Sharon L.; Bucher, Linda; Bucher, Linda; Dirksen, Shannon Ruff; Dirksen, Shannon Ruff. Study Guide for Medical-Surgical Nursing - E-Book (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 33). Elsevier Health Sciences. Kindle Edition.

3. a. Patient must desire services and agree in writing that only hospice care can be used to treat the terminal illness (palliative care) b. Patient must meet eligibility, which is less than 6 months to live, certified initially by two physicians Lewis, Sharon L.; Lewis, Sharon L.; Bucher, Linda; Bucher, Linda; Dirksen, Shannon Ruff; Dirksen, Shannon Ruff. Study Guide for Medical-Surgical Nursing - E-Book (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 328). Elsevier Health Sciences. Kindle Edition.

2. Priority Decision: The husband and daughter of a Hispanic woman dying from pancreatic cancer refuse to consider using hospice care. What is the first thing the nurse should do? a. Assess their understanding of what hospice care services are. b. Ask them how they will care for the patient without hospice care. c. Talk directly to the patient and family to see if she can change their minds. d. Accept their decision since they are Hispanic and prefer to care for their own. Lewis, Sharon L.; Lewis, Sharon L.; Bucher, Linda; Bucher, Linda; Dirksen, Shannon Ruff; Dirksen, Shannon Ruff. Study Guide for Medical-Surgical Nursing - E-Book (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 33). Elsevier Health Sciences. Kindle Edition.

2. a. The family may not understand what hospice care is and may need information. Some cultures and ethnic groups may underuse hospice care because of a lack of awareness of the services offered, a desire to continue with potentially curative therapies, and concerns about a lack of minority hospice workers. Lewis, Sharon L.; Lewis, Sharon L.; Bucher, Linda; Bucher, Linda; Dirksen, Shannon Ruff; Dirksen, Shannon Ruff. Study Guide for Medical-Surgical Nursing - E-Book (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 328). Elsevier Health Sciences. Kindle Edition.

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 670). F.A. Davis Company. Kindle Edition.

20. 1. The client has the right to be cared for with respect and dignity. 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. 3. The client has the right to the best care available and to have pain treated, regardless of the potential for hastening death. 4. All clients, even if they are not dying, have the right to holistic and compassionate care. TEST-TAKING HINT: This is an "except" question. All of the answer options except one have correct information. The test taker should read the stem carefully to recognize this type of question. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 680). F.A. Davis Company. Kindle Edition. 2

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." Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 694). F.A. Davis Company. Kindle Edition.

20. 1. This is not answering the client's question. 2. A client with type 2 diabetes has organ damage as a result of the high glucose over time; therefore, most organs are not usable. 3. This is a false statement. The client does not have to will his or her body to science to be a tissue/organ donor. 4. The client can donate corneas, skin, and some joints, but organ donation from clients with type 2 diabetes mellitus usually is not allowed. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 699). F.A. Davis Company. Kindle Edition. 4

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 670). F.A. Davis Company. Kindle Edition.

21. 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. 2. This would be an illegal act on the part of the nurse and would destroy the nurse-client relationship with the family. 3. The stem already indicates the spouse is aware of the situation. 4. This is expressing a personal bias on the part of the nurse. TEST-TAKING HINT: The test taker could eliminate option "2" based on the legal and ethical issues. Option "3" is asking the HCP to do something which has already been done. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 680). F.A. Davis Company. Kindle Edition. 1

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?" Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 694). F.A. Davis Company. Kindle Edition.

21. 1. The nurse should not ask the client "why" he or she does something; this is judgmental. 2. This answer option is giving erroneous information because it is not illegal; it is an organization which supports active euthanasia. 3. This question is not relevant to the situation. 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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 699). F.A. Davis Company. Kindle Edition. 4

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 670). F.A. Davis Company. Kindle Edition.

22. 1. Death from dehydration occurs when the client is unable to take in fluids, but dehydration is not painful. 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. 3. This is needless. 4. Families who make this decision usually do so from a deep sense of love and commitment. It is an extremely difficult decision to make, and the nurse should not condemn the family decision. TEST-TAKING HINT: The test taker could examine options "3" and "4" and eliminate them based on the needless information or the nurse stepping outside of professional boundaries. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 680). F.A. Davis Company. Kindle Edition. 2

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 694). F.A. Davis Company. Kindle Edition.

22. 1. Many Middle Eastern cultures practice this, but the Caucasian culture does not. 2. Caucasians as a culture do not necessarily have a preference, but this does not affect culturally sensitive health care. 3. Frequently Caucasians do not like to talk about death and dying, but this is an individual preference of the client and the nurse should allow the discussion. 4. The western Caucasian society values autonomy and truth telling in individual decision making. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 699). F.A. Davis Company. Kindle Edition. 4

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 694). F.A. Davis Company. Kindle Edition.

23. 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. 2. This is the correct method for disposing of any paper which has client information on it which is not a part of the client's permanent medical record. 3. This is the correct method to indicate a medication was not administered to the client; the circle means the person should go to the nurse's notes to read the reason why the medication was not administered. 4. All narcotics not administered to the client must be verified when being wasted and then documented. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 699). F.A. Davis Company. Kindle Edition. 1

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? Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 670). F.A. Davis Company. Kindle Edition.

23. 1. The family may or may not be angry and this would need to be addressed, but it is not the most important. 2. Who makes the decisions is not as important as discovering which coping skills the family uses when under stress. 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. 4. The type of funeral service may help the family to grieve, but it is not the most important intervention. TEST-TAKING HINT: The test taker must prioritize the interventions listed. All of the interventions could be addressed in option "3." Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 681). F.A. Davis Company. Kindle Edition. 3

24. The client who is terminally ill called the significant others to the room and said goodbye, 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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 670). F.A. Davis Company. Kindle Edition.

24. 1. The client is not denying death; the client has said good-bye. 2. Anger is the second stage of the grieving process, but this client appears to have accepted death. 3. There is no evidence of bargaining in the client's actions. 4. The client has accepted the imminent death and is withdrawing from the significant others. TEST-TAKING HINT: There are five (5) stages to Dr. Elisabeth Kübler-Ross's grieving process, and some authorities list several more, but this behavior could only be withdrawal or acceptance. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 681). F.A. Davis Company. Kindle Edition. 4

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 the fire code does not allow any burning in a hospital. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 695). F.A. Davis Company. Kindle Edition.

24. 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. 2. Having the door shut does not matter; open flames are not allowed in any health-care facility. 3. This is not necessarily true, and if it is part of the cultural beliefs about dying, then the nurse should medicate the client if he or she becomes nauseated. 4. This is a fact, but the nurse should attempt to compromise and support the client and family's cultural needs, especially at the time of death. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 700). F.A. Davis Company. Kindle Edition. 1

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 670). F.A. Davis Company. Kindle Edition.

25. 1. Blood pressure elevates in acute pain. Chronic pain, by definition, lasts more than six (6) months, lasts far beyond the expected time for the pain to resolve, and may have an unclear onset. Changes in vital signs result from the fight-or-flight response by the body. The body cannot maintain this response and must adjust. 2. Rapid shallow respirations might be attributed to acute pain if it was painful to breathe. The client with a chest injury or pain will splint the area and slow the respirations or attempt to breathe shallowly and rapidly. 3. Facial grimacing will occur in acute pain and is an objective sign the nurse can identify. Clients with chronic pain may be laughing and still be in pain. Remember, pain is whatever the client says it is and occurs whenever the client says it does. 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. TEST-TAKING HINT: The test taker must be able to differentiate between acute and chronic pain. Options "1," "2," and "3" are objective symptoms of acute pain. If the test taker were aware of this, then choosing the only option left would be a good choice. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 681). F.A. Davis Company. Kindle Edition. 4

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 Table 18-1), 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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 695). F.A. Davis Company. Kindle Edition.

25. 1. There is no need to report this action to the state board; this is not malpractice. 2. This action does not warrant the nurse being terminated. 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. 4. The ANA cannot discipline nurses; it is a voluntary nurse's organization. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 700). F.A. Davis Company. Kindle Edition. 3

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 670). F.A. Davis Company. Kindle Edition.

26. 1. Pain is whatever the client says it is and occurs whenever the client says it does. The nurse should never deny the client's pain exists. 2. This has been occurring for the past three (3) years and does not mean the cancer has come back. Many clients will fear the cancer has recurred and delay treatment; denial is a potent coping mechanism. 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. 4. There are many problems associated with long-term narcotic use. Other strategies should be attempted prior to resigning the client to a lifetime of taking narcotic medications. TEST-TAKING HINT: The test taker could eliminate option "1" because it violates all principles of pain management. Option "2" is not in the realm of the nurse's responsibility. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 681). F.A. Davis Company. Kindle Edition. 3

26. The wife of a client receiving hospice care being cared for at home calls the nurse to report the client is restless and agitated. Which interventions should the nurse implement? List in order of priority. 1. Request an order from the health-care provider for antianxiety medications. 2. Call the medical equipment company and request oxygen for the client. 3. Go to the home and assess the client and address the wife's concerns. 4. Reassure and calm the wife over the telephone. 5. Notify the chaplain about the client's change in status. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 695). F.A. Davis Company. Kindle Edition.

26. In order of priority: 4, 3, 2, 1, 5. 4. The nurse should calm and reassure the wife over the telephone. 3. The nurse should then visit the client immediately to assess the change in condition. 2. Restlessness and agitation are symptoms of lack of oxygen. Therefore, calling the medical equipment company to send oxygen would be the next intervention. 1. Terminal restlessness is difficult for the family to watch and the client to experience, so antianxiety medications would be the next logical intervention. 5. Referral to the chaplain is needed because death may be imminent. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 700). F.A. Davis Company. Kindle Edition.

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." Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 671). F.A. Davis Company. Kindle Edition.

27. 1. This is a therapeutic response and the client is requesting information. 2. Pain clinics do not cure pain; they do help identify measures to relieve pain. 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. 4. This is not an appropriate answer, even if the nurse is not sure. The nurse should attempt to discover the information for the client and then give factual information. TEST-TAKING HINT: The test taker should answer a question with factual information. If the stem asks for a therapeutic response, then the test taker should choose one which addresses feelings. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 682). F.A. Davis Company. Kindle Edition. 3

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." Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 673). F.A. Davis Company. Kindle Edition.

49. 1. There is a feeling during times of stress that organs may be distributed unfairly. Tissue and organ banks use the United Network of Organ Sharing (UNOS) to be as fair as possible in the allocation of organs and tissues. Organs will be given to the best match for the organ in the community where the donor dies. If no match is found in that area, then the search for an HLA match will be expanded to other areas of the country. The recipient is chosen based on HLA match, not fame or fortune. 2. The client is asking for information, which the nurse should provide. 3. There is a definite method of allocation of organs. 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. TEST-TAKING HINT: Option "2" can be eliminated because the client asked for information. Option "1" can be eliminated because the statement supports an unethical situation. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 687). F.A. Davis Company. Kindle Edition. 4

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 671). F.A. Davis Company. Kindle Edition.

28. 1. NSAIDs around the clock are dangerous because of the potential for gastrointestinal ulceration. NSAIDs are not the drug of choice for cancer pain. 2. Morphine is the drug of choice for cancer pain. There is no ceiling effect, it metabolizes without harmful by-products, and it is relatively inexpensive. A sustainedrelease 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. 3. Tylenol is not strong enough for this client's pain. The maximum adult dose within a 24-hour period is four (4) g. Tylenol is toxic to the liver in higher amounts. 4. Meperidine (Demerol) metabolizes into normeperidine and is not cleared by the body rapidly. A buildup of normeperidine can cause the client to seize. TEST-TAKING HINT: The test taker must be aware of medications and their uses. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 682). F.A. Davis Company. Kindle Edition. 2

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." Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 671). F.A. Davis Company. Kindle Edition.

29. 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. 2. There can be several reasons a legitimate prescription is not filled. 3. Morphine needs a handwritten prescription on a triplicate form. 4. All medications have side effects; most notably, narcotics slow peristalsis and cause constipation. TEST-TAKING HINT: The test taker could eliminate both options "1" and "2" because they are opposites. Option "4" is untrue of all medications. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 682). F.A. Davis Company. Kindle Edition. 1

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 668). F.A. Davis Company. Kindle Edition.

3. 1. A client diagnosed with Guillain-Barré syndrome is mentally competent, and being on a ventilator does not indicate the client has lost his or her decision-making capacity. 2. A client in the rehabilitation unit would be alert, and spinal cord injuries do not cause the client to lose decision-making capacity. 3. The client must have lost decision-making 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. 4. A client with Down syndrome may have some mental challenges, but unless the client has been declared legally incompetent in a court of law, the client can complete an AD and participate in his/her own case. TEST-TAKING HINT: If the test taker knows what an AD is, then the words "end-stage" and "comatose" would lead the test taker to select option "3" as a correct answer. Remember, clients with congenital or genetic disorders are not incompetent, even if they are mentally challenged. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 676). F.A. Davis Company. Kindle Edition. 3

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." Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 692). F.A. Davis Company. Kindle Edition.

3. 1. Advance directives (AD) are not mandated by the federal government. The nurse must discuss this with the client, but the client does not have to complete it. 2. ADs can be overridden by the family because the health-care provider is worried about being sued by family survivors. 3. This response is not answering the client's question and it is argumentative. 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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 696). F.A. Davis Company. Kindle Edition. 4

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? _________ Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 671). F.A. Davis Company. Kindle Edition.

30. 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 TEST-TAKING HINT: The nurse is responsible for being knowledgeable of all medications and the amount the client is receiving. The test taker can use the drop-down calculator on the NCLEX-RN examination or ask the examiner for scratch paper. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 682). F.A. Davis Company. Kindle Edition.

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 671). F.A. Davis Company. Kindle Edition.

31. 1. The client is in pain and has the right to have pain-control measures taken. 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. 3. The client may be splinting to prevent the pain from being too severe. The client's respirations actually may improve when the nurse administers the pain medication. 4. The HCP is aware the client is unstable because the HCP must write the DNR order on the chart. There is no reason to withhold needed medication. TEST-TAKING HINT: The position of administering medication which could hasten a client's death is a difficult one and requires the nurse to be aware of ethical position statements. Nurses never administer medications for the purpose of hastening death but sometimes must administer medications to provide what nurses do best, comfort. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 683). F.A. Davis Company. Kindle Edition. 2

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 671). F.A. Davis Company. Kindle Edition.

34. 1. The TENS unit does not deaden nerve endings; this would be accomplished through local anesthesia. 2. The unit could stop functioning if it got wet, but this would not cause paralysis. 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. 4. The TENS unit should be applied and left in place unless the client is showering. TEST-TAKING HINT: A medical device which causes paralysis so easily would not be approved for use by the general population, so option "2" could be eliminated. The test taker would need to be aware of the gate control theory of pain control to eliminate the other options. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 683). F.A. Davis Company. Kindle Edition. 3

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 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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 671). F.A. Davis Company. Kindle Edition.

32. 1. This hemoglobin is low but would be expected for a client diagnosed with leukemia. A less experienced nurse could care for this client. Leukemia affects production of all cells produced by the bone marrow—either there is too much production of immature cells overpowering the ability of the bone marrow to use the pluripotent cells to produce other needed blood cells or because the bone marrow is not producing enough cells as needed. It effectively produces a pancytopenia. 2. This represents an arterial blood gas of less than 60%; this client should be assigned to the most experienced nurse. 3. A client who needs a colostomy irrigated could be assigned to a less experienced nurse. 4. Psychological problems come second to physiological ones. TEST-TAKING HINT: This is a priority question. The test taker should realize option "1" is expected and may even be good for this client; option "3" is expected and not life threatening; and option "4," although not expected, is not life threatening. By doing this, the test taker could then look at what was determined for each option and realize option "2" needs the most experienced nurse. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 683). F.A. Davis Company. Kindle Edition. 2

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 671). F.A. Davis Company. Kindle Edition.

33. 1. The UAP could perform this function. 2. The UAP could perform this function. 3. The UAP could perform this function. 4. The nurse should monitor any laboratory work needed to administer a medication safely. TEST-TAKING HINT: The rules for delegation state assessment, teaching, evaluating, or anything requiring nursing judgment cannot be delegated. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 683). F.A. Davis Company. Kindle Edition. 4

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 672). F.A. Davis Company. Kindle Edition.

35. 1. These are normal arterial blood gases. 2. These temperature, pulse, and respiration rates are only slightly elevated, and the blood pressure is normal. 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. 4. This is considered mild pain, and this client can be seen after the client in chronic pain. TEST-TAKING HINT: Options "1" and "2" could be eliminated because the values are within normal limits or only slightly above normal. Option "4" could be eliminated because three (3) is low on the 1-to-10 pain scale. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 683). F.A. Davis Company. Kindle Edition. 3

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 672). F.A. Davis Company. Kindle Edition.

36. 1. This could be appropriate once the nurse assesses the situation further. 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. 3. This is not appropriate. It is in the nurse's realm of responsibility to investigate the client's reasons for not wanting to take pain medication. 4. Chronic cancer pain does not resolve on its own. TEST-TAKING HINT: Option "1" is advising without assessing. Assessment is the first step of the nursing process and should be implemented first in most situations unless a direct intervention treats the client in an emergency. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 684). F.A. Davis Company. Kindle Edition. 2

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 672). F.A. Davis Company. Kindle Edition.

37. 1. This is an example of assault, which is a mental or physical threat without touching the client. 2. When a mentally competent adult is forced to have a treatment he or she has refused, battery occurs. 3. This is fraud, a willful and purposeful misrepresentation which could cause harm to a client. 4. This is called defamation, a divulgence of privileged information or communication. This is a violation of the Health Insurance Portability and Accountability Act (HIPAA). TEST-TAKING HINT: If the test taker knows battery is "bad," it may lead to selecting option "2," which has "forcibly" in the stem. The test taker could attempt to eliminate options based on knowledge. For example, breaking confidentiality is a violation of HIPAA; thus option "4" can be eliminated. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 684). F.A. Davis Company. Kindle Edition. 2

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 672). F.A. Davis Company. Kindle Edition.

38. 1. The Health Insurance Portability and Accountability Act (HIPAA) is a federal act protecting the client's privacy while receiving health care. 2. The state Nurse Practice Acts provides the laws which control the practice of nursing in each state. 3. There is no such law as this act. 4. The Good Samaritan Act protects healthcare practitioners against malpractice claims for care provided in emergency situations. TEST-TAKING HINT: The test taker should be knowledgeable of the Good Samaritan Act and its implications in the nurse's professional career. The NCLEX-RN often asks questions on this act. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 684). F.A. Davis Company. Kindle Edition. 4

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." Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 672). F.A. Davis Company. Kindle Edition.

39. 1. This response does not support veracity. 2. This response does not support veracity. 3. The principle of veracity is the duty to tell the truth. This response is telling the client the truth. 4. This response does not support veracity. TEST-TAKING HINT: The test taker must know certain ethical principles, such as veracity, beneficence, nonmalfeasance, fidelity, autonomy, and justice, to name a few. Without knowing the definition of veracity, the test taker would not be able to answer this question correctly. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 684). F.A. Davis Company. Kindle Edition. 3

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 668). F.A. Davis Company. Kindle Edition.

4. 1. Individual states are responsible for specific legal requirements for ADs. 2. Moving from one state to another does not nullify or honor the AD; the nurse must be aware of the individual state's requirements. 3. Only the individual can complete and sign an AD. The significant other may be asked to implement the AD. 4. The state determines the definition of terms and requirements for an AD; individual states are responsible for specific legal requirements for ADs. TEST-TAKING HINT: The test taker should know the registered nurse must obtain a copy of the Nurse Practice Act of the state he or she is practicing in. The test taker should realize every state has different regulations regarding ADs and other health-care issues. Option "4" is the only option which reflects this thought. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 676). F.A. Davis Company. Kindle Edition. 4

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 692). F.A. Davis Company. Kindle Edition.

4. 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. 2. The hospital supervisor does not need to be notified the family did not want to come to the hospital. 3. The nurse needs to take care of the client, not the family, and should not call to request a rabbi to go visit the family. 4. The nurse must be aware of cultural differences and not be judgmental. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 696). F.A. Davis Company. Kindle Edition. 1

4. For each of the following body systems, identify three physical manifestations that the nurse would expect to see in a patient approaching death. Respiratory a. b. c. Skin a. b. c. Gastrointestinal a. b. c. Musculoskeletal a. b. c. Lewis, Sharon L.; Lewis, Sharon L.; Bucher, Linda; Bucher, Linda; Dirksen, Shannon Ruff; Dirksen, Shannon Ruff. Study Guide for Medical-Surgical Nursing - E-Book (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 33). Elsevier Health Sciences. Kindle Edition.

4. Respiratory a. Cheyne-Stokes respiration b. Death rattle (inability to cough and clear secretions) c. Increased, then slowing, respiratory rate (Also: irregular breathing, terminal gasping) Skin a. Mottling on hands, feet, and legs that progresses to the torso b. Cold, clammy skin c. Cyanosis on nose, nail beds, and knees (Also: waxlike skin when very near death) Gastrointestinal a. Slowing of the gastrointestinal tract with accumulation of gas and abdominal distention b. Loss of sphincter control with incontinence c. Bowel movement before imminent death or at time of death Musculoskeletal a. Loss of muscle tone with sagging jaw b. Difficulty speaking c. Difficulty swallowing (Also: loss of ability to move or maintain body position, loss of gag reflex) Lewis, Sharon L.; Lewis, Sharon L.; Bucher, Linda; Bucher, Linda; Dirksen, Shannon Ruff; Dirksen, Shannon Ruff. Study Guide for Medical-Surgical Nursing - E-Book (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 328). Elsevier Health Sciences. Kindle Edition.

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 672). F.A. Davis Company. Kindle Edition.

40. 1. The surgeon is responsible for explaining the surgical procedure to the client; therefore, the nurse should first notify the surgeon. 2. This information should be documented on the chart, but it is not the first intervention. 3. The operating room staff may or may not need to be notified based on when or if the permit is being signed, but it is not the first intervention. 4. The nurse is not responsible for explaining the surgical procedure. The nurse is responsible for making sure the client understands and for obtaining the consent. TEST-TAKING HINT: The nurse is responsible for getting the permit signed and on the chart prior to going to surgery, but the nurse is not responsible for explaining the procedure to the client. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 684). F.A. Davis Company. Kindle Edition. 1

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 672). F.A. Davis Company. Kindle Edition.

41. 1. Wearing their own clothes, keeping personal items, and having a small amount of money are civil rights of clients in a psychiatric unit. 2. Seeing visitors is a civil right of the client. 3. Receiving and sending unopened mail is a civil right of the client, but any packages must be inspected when the client is opening them to check for sharp items, weapons, or any type of medications. 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. TEST-TAKING HINT: The test taker must be aware of the client's legal and civil rights. The client in the psychiatric unit has the same rights as the client in the medical unit. Clients in a psychiatric hospital do not have to wear hospital gowns; they can wear their own clothes. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 685). F.A. Davis Company. Kindle Edition. 4

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 672). F.A. Davis Company. Kindle Edition.

42. 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 healthcare team. 2. Self-determination is not an ethical principle. 3. Beneficence is the duty to actively do good for clients. 4. Justice is the duty to treat all clients fairly. TEST-TAKING HINT: The test taker should be aware of ethical principles which mandate a nurse's behavior. Clients have rights, and autonomy is an important principle which the nurse must ensure every client has. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 685). F.A. Davis Company. Kindle Edition. 1

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 672). F.A. Davis Company. Kindle Edition.

43. 1. The Hippocratic Oath is the oath taken by medical doctors. 2. The Nuremberg Code identifies the need for voluntary informed consent when medical experiments are conducted on human beings. This source does not provide direction for the nurse addressing ethical issues. 3. This document informs clients and families receiving home health care of the ethical conduct they can expect from home care agencies and their employees when they are in the home. This source is not the best professional source for all nurses. 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. TEST-TAKING HINT: The test taker must be aware of the word "best" to be able to answer this question. All four (4) answer options may or may not be potential answers, but the test taker must select the option which addresses all nurses. Option "3" should be eliminated as a possible answer because it only addresses home health care. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 685). F.A. Davis Company. Kindle Edition. 4

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 672). F.A. Davis Company. Kindle Edition.

44. 1. Breach of duty is one (1) of the four (4) elements necessary to prove nursing malpractice. It is failure to perform according to the established standard of conduct. 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. 3. Failure to meet the standard of care resulting in an actual injury or damage to the client is required to prove nursing malpractice. 4. A connection must exist between conduct and the resulting injury to prove nursing malpractice. TEST-TAKING HINT: This is a knowledge-based question, but the test taker should realize ethical issues and legal issues are two different concerns and that malpractice is a legal concern. The test taker should also know the four (4) elements necessary to prove nursing malpractice: (1) The nurse has a duty to the client. (2) The duty has been breached. The nurse failed to uphold a standard of care. (3) There is some harm to the client. (4) The breach of duty caused the harm. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 685). F.A. Davis Company. Kindle Edition. 2

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 673). F.A. Davis Company. Kindle Edition.

45. 1. This action should be taken, but this is not the first action to keep the client safe. 2. This is a form of chemical restraint, and the nurse must have a health-care provider's order. 3. This is a form of restraint and is against the law unless the nurse has a health-care provider's 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. TEST-TAKING HINT: The test taker must realize when the stem asks which action is first; more than one option may be appropriate for the situation, but only one is implemented first. Restraining a client is considered battery and is against the law unless the client is a danger to self and there is a health-care provider's order. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 686). F.A. Davis Company. Kindle Edition. 4

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 673). F.A. Davis Company. Kindle Edition.

46. 1. Nurse Practice Acts provide the laws which control the practice of nursing in each state. All states have Nurse Practice Acts. 2. The Client's Bill of Rights, also known as "Your Rights as a Hospital Patient," is a document which explains the client's rights to participate in his or her own health care; it does not address the nurse's behavior. 3. Each state, not the U.S. Congress, is responsible for writing and implementing the state's Nurse Practice Act. 4. The American Nurses Association is a voluntary organization which provides standards of care and a code of ethics. It addresses issues in nursing, but it does not mandate the registered nurse's behavior. TEST-TAKING HINT: This is a knowledgebased question which the test taker must know. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 686). F.A. Davis Company. Kindle Edition. 1

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 673). F.A. Davis Company. Kindle Edition.

47. 1. This addresses the ethical principle of veracity. Should the nurse tell the client truthfully a placebo will not help the pain? 2. This is an example of nonmalfeasance, the duty to prevent or avoid doing harm, whether intentional or unintentional. Is it harmful for a nurse to work in an area where he or she is not experienced? 3. This is an example of the ethical principle of fidelity, the duty to be faithful to commitments. It involves keeping promises and information confidential and maintaining privacy. 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. TEST-TAKING HINT: The test taker must be knowledgeable of ethical principles; they are part of the NCLEX-RN blueprint. The word "justice" should make the test taker think about fairness, which might lead the test taker to select option "4" as the correct answer. The test taker should not automatically think, "I don't know the answer." Think about the words before selecting the correct answer. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 686). F.A. Davis Company. Kindle Edition. 4

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 673). F.A. Davis Company. Kindle Edition. 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

48. 1. The law states child abuse or suspected child abuse must be reported. The nurse is legally responsible to report child abuse or suspected child abuse. This is a legal issue, not malpractice. 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. 3. Stealing narcotics is a legal situation, not a malpractice issue. The nurse could have his or her nursing license revoked for this illegal behavior. 4. Falsifying documents is against the law. It is not a malpractice issue. TEST-TAKING HINT: The test taker must be knowledgeable of malpractice. Legal issues are dealt with by the laws of the state and federal government, and malpractice issues are dealt with in the state Nurse Practice Acts and in lawsuits in courts of law. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 686). F.A. Davis Company. Kindle Edition. 2,3,4

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 668). F.A. Davis Company. Kindle Edition.

5. 1. ADs are more frequently completed by white, middle- to upper-class individuals. 2. Many nurses do not have ADs, although they discuss them with clients daily. 3. Culturally, Hispanics allow their family members to make decisions for them. 4. Many cultures, including the African American culture, often distrust the health-care system and believe necessary care will be withheld if an AD is completed. TEST-TAKING HINT: If the test taker were not aware of the research, the test taker could examine the occupations and ask themselves, "Which client would want to direct his or her own care and make his or her own decisions?" Nurses may want this but many do not have ADs. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 677). F.A. Davis Company. Kindle Edition. 1

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 692). F.A. Davis Company. Kindle Edition.

5. 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. 2. This is an appropriate intervention, but the nurse must first talk directly to the client. 3. After one (1) year, the wife should be progressing through the grieving process and needs encouragement to remove her husband's belongings. 4. This will need to be done at some point, but it is not the nurse's responsibility. This action is crossing professional boundaries unless the wife asks the nurse to do this. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 696). F.A. Davis Company. Kindle Edition. 1

5. Priority Decision: A terminally ill patient is unresponsive and has cold, clammy skin with mottling on the extremities. The patient's husband and two grown children are arguing at the bedside about where the patient's funeral should be held. What should the nurse do first? a. Ask the family members to leave the room if they are going to argue. b. Take the family members aside and explain that the patient may be able to hear them. c. Tell the family members that this decision is premature because the patient has not yet died. d. Remind the family that this should be the patient's decision and to ask her if she regains consciousness. Lewis, Sharon L.; Lewis, Sharon L.; Bucher, Linda; Bucher, Linda; Dirksen, Shannon Ruff; Dirksen, Shannon Ruff. Study Guide for Medical-Surgical Nursing - E-Book (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 34). Elsevier Health Sciences.

5. b. Hearing is often the last sense to disappear with declining consciousness and conversations can distress patients even when they appear unresponsive. Conversation around unresponsive patients should never be other than that which one would maintain if the patients were alert. Lewis, Sharon L.; Lewis, Sharon L.; Bucher, Linda; Bucher, Linda; Dirksen, Shannon Ruff; Dirksen, Shannon Ruff. Study Guide for Medical-Surgical Nursing - E-Book (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 328). Elsevier Health Sciences. Kindle Edition.

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 673). F.A. Davis Company. Kindle Edition.

50. 1. Positive brain waves on the EEG indicate brain activity, and the client is not brain dead. 2. This is called the oculovestibular test. If the client reacts, then it indicates brain activity and the client is not brain dead. 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. 4. If the cerebral blood flow studies do not show acceptable blood flow to the brain, the client will not come out of the vegetative state. TEST-TAKING HINT: If the test taker examined all answer options and did not understand options "1," "2," and "4," then reading option "3" again would prove it to be the best choice because it simply states the machine won't be turned off until brain death has been proved. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 687). F.A. Davis Company. Kindle Edition. 3

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 673). F.A. Davis Company. Kindle Edition.

51. 1. Many states require tissue and organ banks to be notified of all deaths, but the systemic infection eliminates this client from becoming a donor. 2. Septicemia is a systemic infection and will prevent the client from donating tissues or organs. 3. There is no reason to notify the HCP. 4. If the client were to be an organ donor, then the client's body would remain in the intensive care unit on the ventilator and with IV medication support until the organ bank team arrives and takes the client to the operating room. TEST-TAKING HINT: Option "3" could be eliminated from consideration because the nurse should be able to handle this situation. Option "4" could be eliminated because the client would have to stay on life support if the organ bank were to retrieve viable organs. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 687). F.A. Davis Company. Kindle Edition. 2

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 673). F.A. Davis Company. Kindle Edition.

52. 1. Oliguria, fever, increasing edema, hypertension, and weight gain are signs of organ rejection. 2. A decrease in serum creatinine and BUN would indicate the transplanted kidney is functioning well. 3. Potassium and calcium are not monitored for rejection. 4. The client with a fever might have tachycardia. Hypertension is a sign of rejection. TEST-TAKING HINT: Option "2" could be eliminated because of the word "decreased." If the test taker were aware of the role the kidneys play in controlling blood pressure, then option "4" could be eliminated. Decreased urine output in option "1" would make the most sense to choose because the kidneys produce urine. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 687). F.A. Davis Company. Kindle Edition. 1

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 antirejection drugs. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 673). F.A. Davis Company. Kindle Edition.

53. 1. The client must take an immune-suppressant medication forever unless a rejection occurs, and then the client would die without another transplant. 2. Foul-smelling drainage would indicate infection and is not expected. This would be an emergency situation. 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. 4. The skin turns yellow in liver failure; the antirejection drugs do not cause jaundice. TEST-TAKING HINT: Standard postoperative instructions include teaching the client to watch for any sign of an infection. Foulsmelling drainage is never normal. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 688). F.A. Davis Company. Kindle Edition. 3

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 674). F.A. Davis Company. Kindle Edition.

54. 1. There is no pain associated with storing cord blood. The blood is taken from the separated placenta at birth. Forty to 150 mL of stem cells can be retrieved from the umbilical vein. 2. All hospitals which have an obstetrics department should be able to assist with the collection of stem cells. The client should notify the HCP to be prepared with the kit to obtain the specimens and to be able to send the stem cells to the Cord Blood Registry for processing and storage. 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. 4. This is true of stem cells which have been stored for more than 20 years. TEST-TAKING HINT: The test taker should recognize pain could not be associated with tissue which is no longer a part of the body. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 688). F.A. Davis Company. Kindle Edition. 3

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 674). F.A. Davis Company. Kindle Edition.

55. 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. 3. Serum creatinine and BUN levels are monitored, but there is no need to monitor the urine osmolality. 4. Hourly outputs are monitored and compared with the intake of fluids. 5. The dressing is a flank dressing. TEST-TAKING HINT: The test taker should notice time frames. Anytime a specific time reference is provided, the test taker must determine if the time frame is the appropriate interval for performing the activity. In option "4," "every shift" is not appropriate. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 688). F.A. Davis Company. Kindle Edition. 1,2

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 antirejection medication. 2. The client has difficulty coming off the heartlung 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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 674). F.A. Davis Company. Kindle Edition.

56. 1. The client would be NPO at this time and would be receiving parenteral antirejection medications. 2. The client would have been taken off the heart-lung bypass machine in the operating room. 3. Saturating three (3) dressing pads in one (1) hour would indicate hemorrhage. 4. Pain is expected and is not a complication of the procedure. TEST-TAKING HINT: The test taker should notice the time frame provided in the stem—in this case, three (3) hours after surgery. This could eliminate options "1" and "2." Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 688). F.A. Davis Company. Kindle Edition. 3

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 674). F.A. Davis Company. Kindle Edition.

57. 1. Assessment is always the nurse's responsibility and cannot be delegated. Hourly outputs are monitored to determine kidney function. 2. The UAP can perform this function. There is no nursing judgment required. 3. This requires nursing judgment and is outside the UAP's expertise. 4. Irrigating a nasogastric tube for a client who has undergone a pancreas transplant should be done by the nurse; this is a high-level nursing task. TEST-TAKING HINT: When asked to choose a task which can be delegated, the test taker should determine which task requires the least amount of judgment and choose that option. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 688). F.A. Davis Company. Kindle Edition. 2

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 674). F.A. Davis Company. Kindle Edition.

58. 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. 2. This client must be observed closely for rejection of the organ and is newly transferred from the intensive care unit; therefore, a more experienced nurse in transplant care should care for this client. 3. This client has developed symptoms of a problem unrelated to the corneal transplant, but these symptoms will increase intracranial pressure, resulting in indirect pressure to the cornea. Therefore, a more experienced transplant nurse should care for this client. 4. This client is showing symptoms of organ rejection, which is a medical emergency and requires a more experienced transplant nurse. TEST-TAKING HINT: The test taker should choose the client with the fewest potential problems. The nurse is experienced as a medical-surgical nurse, but transplant recipients require more specialized knowledge. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 689). F.A. Davis Company. Kindle Edition. 1

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 674). F.A. Davis Company. Kindle Edition.

59. 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. 2. The father would have only half of the genetic makeup of the child. 3. There are at least 27 HLA types. A match requires at least 7, and preferably 10 to 11 points. 4. This is not an acceptable match; the client would reject the organ. TEST-TAKING HINT: If the test taker did not know the rationale, then a choice between options "1" and "2" would be the best option because of the direct familial relationships. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 689). F.A. Davis Company. Kindle Edition. 1

6. The nurse is giving an in-service on end-of lifeissues. 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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 692). F.A. Davis Company. Kindle Edition.

6. 1. This activity will not help the nurse address his or her own fear of death. 2. This activity will not help the nurse address his or her own fear of death. 3. This activity will not help the nurse address his or her own fear of death. 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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 697). F.A. Davis Company. Kindle Edition. 4

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 668). F.A. Davis Company. Kindle Edition.

6. 1. This department has nothing to do with the AD. 2. The most appropriate action would be for the nurse to have the client write on the AD he or she is revoking the document; the nurse cannot shred legal documents from the client's chart. 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. 4. This is an incorrect answer because the client always has the right to change his or her mind. TEST-TAKING HINT: Option "4" can be eliminated by remembering statements with absolutes should not be selected as correct answers unless the test taker knows for sure the answer is correct. The client's chart is a legal document, and these papers cannot be shredded or altered by using anything that obscures the writing or by erasing information. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 677). F.A. Davis Company. Kindle Edition. 3

6. A 20-year-old patient with a massive head injury is on life support, including a ventilator to maintain respirations. What three criteria for brain death are necessary to discontinue life support? a. b. c. Lewis, Sharon L.; Lewis, Sharon L.; Bucher, Linda; Bucher, Linda; Dirksen, Shannon Ruff; Dirksen, Shannon Ruff. Study Guide for Medical-Surgical Nursing - E-Book (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 34). Elsevier Health Sciences. Kindle Edition.

6. a. Coma b. Absent brainstem reflexes c. Apnea Lewis, Sharon L.; Lewis, Sharon L.; Bucher, Linda; Bucher, Linda; Dirksen, Shannon Ruff; Dirksen, Shannon Ruff. Study Guide for Medical-Surgical Nursing - E-Book (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 328). Elsevier Health Sciences. Kindle Edition.

60. Which tissue or organ can be repeatedly donated to clients needing a transplant? 1. Skin. 2. Bones. 3. Kidneys. 4. Bone marrow. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 674). F.A. Davis Company. Kindle Edition.

60. 1. Skin is taken from cadaver donors, so it is given once. 2. Bones are taken from cadaver donors, so it is given once. 3. A kidney can be donated while the donor is living or both can be donated as cadaver organs, but either way the donation is only once. 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. TEST-TAKING HINT: The test taker could eliminate option "3" because the stem asks for repeated times and the client cannot live without kidney function. The client would have to be placed on dialysis or he or she would die. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 689). F.A. Davis Company. Kindle Edition. 4

61. The nurse is admitting a client to the medicalsurgical unit. Which is required to be offered to the client if the hospital accepts Medicare reimbursement? 1. The opportunity to make an advance directive. 2. The client must be referred to a case manager. 3. The client must apply for a Medicare supplement insurance. 4. The opportunity to discuss end-of-life issues. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 675). F.A. Davis Company. Kindle Edition.

61. 1. In the 1990s, Congress added the requirement for health-care facilities to offer clients the opportunity to receive an advance directive form and to be able to complete it to provide the health-care team with knowledge of the clients' wishes. It was added to a Medicare funding bill. 2. The client has to refuse or accept or alert the facility of an intact document about advanced decisions made by the client, but referral to a case manager is not attached to Medicare funding, 3. The client does not have to apply for supplemental insurance. 4. The opportunity may include end-of-life issues but it is not limited to end of life; it does include issues of irreversible situations and surrogate decision makers. TEST-TAKING HINT: The test taker could eliminate option "3" because the nurse cannot make the client do anything. The client has a right to say no. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 690). F.A. Davis Company. Kindle Edition. 1

62. The nurse pronounced Dr. Smith's client to be clinically dead. Which should the nurse document on the client's chart? 1. Brain scan indicates no brain wave activity, client pronounced deceased. Family refuses to talk with organ bank. 2. Cardiac arrest noted, CPR initiated but unsuccessful. Pronounced dead. 3. Pulse, respirations, and blood pressure absent at 0900, pronounced dead. Dr. Smith to sign death certificate. 4. Client found without pulse, body cold to touch. Pronounced deceased at 0900. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 675). F.A. Davis Company. Kindle Edition.

62. 1. Clinical death is the absence of pulse, respirations, and blood pressure. It does not include radiology or other diagnostic tests. 2. If cardiopulmonary resuscitation is unsuccessful, the nurse cannot pronounce death. A physician must determine the reason for the death. 3. For it to be legal for a nurse to pronounce death, the client must have a disease process that could lead to death. The physician must write a clear order that the nurse can pronounce and be willing to document the cause of death on the death certificate. The observed clinical signs must be documented and the time pronounced. 4. This is an incomplete entry. TEST-TAKING HINT: The test taker could eliminate option "1" because clinical death is the absence of clinical signs of life. Option "3" is a complete documentation; the nurse states the facts without embellishment in documentation. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 690). F.A. Davis Company. Kindle Edition. 3

63. The nurse is caring for an 82-year-old female client who is crying and asking for her mother to come to see her. Which statement represents the ethical principle of nonmalfeasance? 1. "You must miss your mother very much. Can you tell me about her?" 2. "You are 82 years old. Your mother is dead and can't come see you." 3. "Why do you need your mother? Can I get something for you?" 4. "Your mother would not want you to worry. I will tell her you want to see her." Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 675). F.A. Davis Company. Kindle Edition.

63. 1. The nurse is caring for a client who is at best disoriented; challenging this cognitive deficiency will only create frustration and anxiety in the client. Nonmalfeasance is the duty to prevent or do no harm. This is a therapeutic response that validates the client's concern but does not include lying to the client. 2. This is veracity, to tell the truth. 3. The client does not owe the nurse an explanation of why she wishes to see her mother. "Why" is not appropriate in this situation. 4. This is the opposite of veracity; it is lying to the client. If the nurse believes the client's mother to be dead, then how will the nurse contact her? TEST-TAKING HINT: The test taker could eliminate option "2" because it is veracity and "4" because it is lying. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 690). F.A. Davis Company. Kindle Edition. 1

64. The hospice nurse is admitting a client. Which question concerning end-of-life care is most important for the nurse to discuss with the client and family? 1. Encourage the client and family to make funeral arrangements. 2. Assess the client's pain medication regimen for effectiveness. 3. Determine if the client has made an advance directive or living will. 4. Ask what durable medical equipment is in place in the home. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 675). F.A. Davis Company. Kindle Edition.

64. 1. The nurse could possibly help the family to guide them about the need for eventual arrangements, but it is not appropriate during the admission process. 2. The client may or may not have pain; nothing indicates pain is an issue in the stem of the question. 3. Advance directives provide guidance for end-of-life care; the nurse needs this information in order to plan the care per the client's wishes. 4. This could be determined, but the priority is knowing the client's wishes. TEST-TAKING HINT: The test taker should recognize timing when reading a stem or option in a question. "On admission," "every day," "every two hours" will help to determine a correct answer. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 690). F.A. Davis Company. Kindle Edition. 3

65. The client is dying and wants to talk to the nurse about heaven. Which is the nurse's best nursing action? 1. Make a referral to the chaplain to come to see the client. 2. Tell the client that nurses are not allowed to discuss spiritual matters. 3. Ask the client to describe heaven and hell. 4. Allow the client to discuss the beliefs about heaven. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 675). F.A. Davis Company. Kindle Edition.

65. 1. Chaplains work with all faiths and are spiritual advisors. If the nurse feels comfortable with discussing heaven and if the client wishes to talk with the nurse, it is appropriate. 2. Nurses are not prohibited from discussing spiritual issues with a client; the nurse should not challenge the client's personal beliefs. 3. Hell is not what the client wants to talk about. 4. The nurse should allow the client to verbalize his/her feeling regarding what to expect when death occurs. TEST-TAKING HINT: The nurse student is taught in first-level courses to allow the client to verbalize feeling; the test taker should recognize this as basic nursing skills. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 691). F.A. Davis Company. Kindle Edition. 4

66. The male client in the long-term care facility has been told that he will not live for many more months. The client has been estranged from his daughter for years. He tells the nurse that he could die a happy man if he could talk to his daughter just one more time. Which statement is the nurse's best response? 1. "You should not feel bad. Things will work out for the best before your death." 2. "What did you do to make your daughter not talk to you all this time?" 3. "If you would like I can try to contact your daughter and ask her to come see you." 4. "Tell me more about being unhappy that you don't have a relationship with your daughter." Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 675). F.A. Davis Company. Kindle Edition.

66. 1. This is false reassurance. 2. The blame for the lack of communication may not be the client's; it could be all on the daughter. This is an accusatory statement. 3. The nurse is asking permission to divulge the client's location and health status to the daughter; this is appropriate for complying with HIPAA and is addressing the voiced concerns of the client. 4. The nurse can perform an intervention that directly affects the client's situation. A therapeutic conversation might be used if the client's daughter is not willing to reconcile with the client. TEST-TAKING HINT: The test taker could eliminate option "1" because it is advising the client about how he should feel. Option "2" asks why and blames the client. Option "4" does not address the client's need. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 691). F.A. Davis Company. Kindle Edition. 3

67. The nurse is caring for the family of the client who has just died. Which is the nurse's priority action? 1. Be with the family. 2. Call the funeral home. 3. Notify the minister. 4. Fill out the death certificate. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 675). F.A. Davis Company. Kindle Edition.

67. 1. When a death occurs the need is for the nurse's presence; just being there with the family is what will help the family grieve. 2. The nurse may need to notify the funeral home, but the family is the priority need. 3. If the family wants the minister to be called, the nurse could do this, but, frequently, the family has a relationship with the minister and will need to speak directly with the minister to arrange the services. 4. The death certificate is completed by the physician signing it, not the nurse. TEST-TAKING HINT: The test taker could eliminate all options besides "1" because none of these will assist the grieving process. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 691). F.A. Davis Company. Kindle Edition. 1

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 668). F.A. Davis Company. Kindle Edition.

7. 1. The HCP should be made aware of the AD, but this is not the first intervention. 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. 3. Copies of the AD should be placed in the chart and given to significant others, the client's attorney, and all health-care providers. 4. The original should be given to the client and a copy should be placed in the chart, but this is not the first intervention. TEST-TAKING HINT: This is a priority-setting question, and the test taker should read all the answer options and try to rank them in order of priority. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 677). F.A. Davis Company. Kindle Edition. 2

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 692). F.A. Davis Company. Kindle Edition.

7. 1. The client has a DNR; therefore, there is no need to bring the crash cart to the bedside. 2. The client has a DNR and the nurse needs to help the client die peacefully. 3. The Catholic religion requires last rites be performed immediately before or after death. 4. The client is Catholic, and there is no specific way for the bed to be placed. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 697). F.A. Davis Company. Kindle Edition. 3

7. A patient with end-stage liver failure tells the nurse, "If I can just live to see my first grandchild who is expected in 5 months, then I can die happy." The nurse recognizes that the patient is demonstrating which of the following stages of grieving? a. Prolonged grief disorder b. Kübler-Ross's stage of bargaining c. Kübler-Ross's stage of depression d. The new normal stage of the Grief Wheel Lewis, Sharon L.; Lewis, Sharon L.; Bucher, Linda; Bucher, Linda; Dirksen, Shannon Ruff; Dirksen, Shannon Ruff. Study Guide for Medical-Surgical Nursing - E-Book (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 34). Elsevier Health Sciences. Kindle Edition.

7. b. Bargaining is demonstrated by "if-then" grief behavior that is described by Kübler-Ross. Kübler-Ross's stage of depression is seen when the person says "yes me, and I am sad." Prolonged grief disorder is seen when there is a dysfunctional reaction to loss and the individual is unable to move forward after the death of a loved one. In the Grief Wheel model, the new normal stage is when the grief is resolved but the normal state, because of the loss, is not the same as before. Lewis, Sharon L.; Lewis, Sharon L.; Bucher, Linda; Bucher, Linda; Dirksen, Shannon Ruff; Dirksen, Shannon Ruff. Study Guide for Medical-Surgical Nursing - E-Book (Study Guide for Medical-Surgical Nursing: Assessment & Management of Clinical Problem) (Page 328). Elsevier Health Sciences. Kindle Edition.

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 668). F.A. Davis Company. Kindle Edition.

8. 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 health-care system. The family has the right to be present and discuss their feelings. 2. The nurse is legally obligated to be a client advocate. 3. This action could create a multitude of ramifications, including a lawsuit and possible criminal charges. 4. It really doesn't matter at this point why the client didn't complete an AD; the client cannot do it now. TEST-TAKING HINT: The test taker must be aware of the ethics committee and its role in helping resolve ethical dilemmas. Any answer option which has the word "why" should be evaluated closely before selecting it as the correct answer. Removing the endotracheal tube or turning off the ventilator ("pulling the plug") is a medical responsibility; therefore, option "3" could be eliminated as the correct answer. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 677). F.A. Davis Company. Kindle Edition. 1

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 692). F.A. Davis Company. Kindle Edition.

8. 1. The hospital should not prevent the client from practicing his or her culture, and denying faith healers would be denying the client's spiritual guidance. 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. 3. There is no reason to refer this client to the pastoral care department; the nurse can assist the client. 4. The nurse does not need to know why the client wants the curandero; the nurse should support the client's request without prejudice. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 697). F.A. Davis Company. Kindle Edition. 2

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 669). F.A. Davis Company. Kindle Edition.

9. 1. It is a power of attorney executed by a lawyer which allows a delegated other person to make financial decisions. That document has nothing to do with a durable power of attorney for health care. 2. The client has not lost the capacity to make decisions; therefore, a durable power of attorney cannot be used by the assigned person to make decisions. 3. The client must not be able to make his or her own decisions before this document can be used. 4. The client must have lost decision-making 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. TEST-TAKING HINT: The test taker should not confuse a power of attorney and a durable power of attorney for health care. These are two separate, yet very important, documents with similar names. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 678). F.A. Davis Company. Kindle Edition. 4

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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 693). F.A. Davis Company. Kindle Edition.

9. 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. 3. The nurse should not tell the family he or she understands; even if the test taker has lost a loved one, the test taker should never select an option which says the nurse understands another person's feelings. 4. This is projecting the nurse's personal religious beliefs on the family and could cause more anger at God when the family needs to be able to draw on their own spiritual beliefs. 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. Colgrove, Kathryn Cadenhead. Med-Surg Success A Q&A Review Applying Critical Thinking to Test Taking (Davis's Q&A Success) (Page 697). F.A. Davis Company. Kindle Edition. 1,2,5