TEST BANK FOR NURSING INTERVENTIONS AND CLINICAL SKILLS 7TH EDITION BY POTTER
Chapter 31: End-of-Life Care Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The nurse is caring for a patient who just died. Which action does the nurse take first to
determine if the patient is an organ or tissue donor? a. Delegate the task to nursing assistive personnel (NAP). b. Determine the patient’s legal representative. c. Request a copy of the patient’s driver’s license. d. Ask the spouse to sign an organ donation consent. ANS: B
The nurse needs to determine if patient is an organ/tissue donor. Federal law mandates that family members be given a chance to authorize organ/tissue donation. The nurse should then call the organ/tissue request and procurement team (consult agency policy). Discussing organ donation and obtaining consent are tasks that the nurse cannot delegate because they require clinical judgment and critical thinking skills and are usually done by a special team. A copy of the patient’s driver’s license can be impractical or impossible to obtain soon enough to donate viable organs; generally the family knows the patient’s wishes about organ donation. If the spouse is the patient’s legal representative, he or she can provide consent. DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation
OBJ: NCLEX: Psychosocial Integrity
2. The family of the patient receiving hospice care is at the bedside expecting an imminent death.
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They become upset when the patient suddenly becomes restless and disoriented. Which action by the nurse is most appropriate? a. Apply oxygen with a face mask. b. Ask the family to leave the room. c. Speak to the patient calmly and softly. d. Administer extra pain medication. ANS: C
Restlessness and agitation are common patient assessments as death approaches and are part of the body’s preparation for death. The nurse explains that the upsetting behavior occurs frequently in the dying process and provides actions for the family to implement. For restlessness and agitation, the family can massage the hands or feet or play soothing music. Oxygen by face mask can increase patient distress and impair any ability to communicate. The nurse avoids asking the family to leave the room. The nurse explains that the patient’s behavior is very common, reflective more of the dying process than actual distress. The nurse administers pain medication according to the prescription and clinical judgment. DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation
OBJ: NCLEX: Psychosocial Integrity
3. During postmortem care, the patient’s family says that the patient didn’t have his dentures to
place in his mouth. Which action does the nurse take at this time? a. Place a rolled-up towel under the patient’s chin. b. Stuff the mouth with cotton to maintain the facial contour.
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