A nurse is caring for a client who has severe head injuries and is declared brain dead. The transplant coordinator has spoken with the client's family about organ donation. The client's spouse states she is confused and does not know what she should do. Which of the following responses by the nurse is appropriate?

"Most religions support organ donation, so don't let that stand in the way."

"There is such a shortage of organs in this country, so I think you should go ahead and consent to donate your spouse's organs."

"Don't you think you will feel a little better about the situation if you donate your spouse's organs?"

"What do you think your spouse would have wanted?"

Answer and Explanation

The Correct Answer is D

A. This response may make the spouse feel pressured by implying that religion should not be a concern, which may not be respectful of the spouse's beliefs.

B. This statement is coercive, focusing on the shortage of organs rather than on the spouse's feelings and the wishes of the deceased.

C. Suggesting that donating organs will make the spouse feel better can be seen as manipulative and may not truly address the spouse's confusion or emotions.

D. Asking what the spouse thinks the deceased would have wanted is appropriate, as it centers on the values and wishes of the deceased, which can guide the spouse in making an informed decision.

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Correct Answer is D

Explanation

A. Documentation of waveform values is important but does not directly enhance patient safety during monitoring.

B. Limiting the pressure tubing length can help maintain accuracy, but it is not the primary safety measure.

C. Zero referencing is crucial for accurate readings, but it must be done in conjunction with ensuring alarms are active.

D. Ensuring that alarm limits are turned on and appropriately set is the best safety measure to immediately alert the nurse to any critical changes in the patient's status.

A. notifying the provider if a 2-lb weight gain occurs in 24 hours. B. taking nitroglycerin if chest pain occurs. C. assessment of an apical pulse. D. compliance with diuretic therapy.

Correct Answer is A

Explanation

A. Sudden weight gain can indicate fluid retention, a common early sign of heart failure exacerbation. Prompt reporting allows for early intervention.

B. Nitroglycerin is used to treat chest pain, not specifically to prevent heart failure exacerbations.

C. Assessment of the apical pulse is important, but monitoring weight is more directly related to managing heart failure.

D. Compliance with diuretic therapy is important, but recognizing early signs of fluid retention, such as rapid weight gain, is crucial for preventing exacerbations.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with a left radial arterial line and a pulmonary artery catheter inserted into the right subclavian vein. Which action by the nurse best ensures the safety of the patient being monitored with invasive hemodynamic monitoring lines?

Correct Answer is D

Explanation

An essential aspect of teaching that may prevent recurrence of heart failure exacerbations is

Correct Answer is A

Explanation

A nurse is performing cardiopulmonary resuscitation (CPR) for an adult client who is unresponsive. The nurse should evaluate the client's circulation by palpating which of the following pulses?

Which of the following describes a situation in which the blood pressure is severely elevated and there is evidence of actual target organ damage?

The nurse is caring for a patient who has an intraaortic balloon pump in place. Which action should be included in the plan of care?

A nurse enters a client's room and finds the client pulseless. The family has requested a do-not-resuscitate (DNR) order from the provider, but he has not written the order yet. Which of the following actions should the nurse take?

A client who has coronary artery disease tells the nurse he is afraid of dying from a heart attack. Which of the following responses should the nurse make?

A nurse is caring for a client who has heart failure and a potassium level of 2.4 mEq/L. The nurse should identify which of the following medications as the cause of the client's low potassium level?

When treating hypertensive emergencies, the nurse identifies the most appropriate route of administration for antihypertensive agents as being which of the following?