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Question 1 of 5

A client receiving end-of-life care is no longer able to make decisions. The client's appointed medical power of attorney (MPOA) is considering placement of a percutaneous enterogastric feeding tube. The MPOA asks the nurse, 'What would you do if this was your family member?' How should the nurse respond?

Correct Answer: C

Rationale: Exploring pros and cons (
C) empowers the MPOA to make an informed decision. Personal opinions (
A), chaplain referral (
B), or family meetings (
D) are less direct.

Question 2 of 5

A 31-year-old client is admitted to the psychiatric unit after cutting both wrists with a kitchen knife. The client has a diagnosis of borderline personality disorder. The most therapeutic approach by the nurse is one that is:

Correct Answer: C

Rationale: A firm and consistent approach provides structure and boundaries, which are therapeutic for clients with borderline personality disorder who often test limits.

Question 3 of 5

An adult is admitted in severe hypovolemic shock following an auto accident. A transfusion is ordered. What type of blood is given when the client's blood type is not known?

Correct Answer: B

Rationale: O negative is the universal donor, safe for emergency transfusions when the blood type is unknown, minimizing reaction risk.

Question 4 of 5

The nurse is caring for a client who is receiving peritoneal dialysis and is reporting chills and abdominal discomfort. The nurse notes rebound tenderness with palpation. Which of the following actions would be a priority for the nurse to take?

Correct Answer: A

Rationale: Chills, discomfort, and rebound tenderness suggest peritonitis, requiring fluid culture (
A). Warming dialysate (
B), pain medication (
C), and positioning (
D) do not address the infection.

Question 5 of 5

Before administering a feeding through a gastrostomy tube, what is the priority nursing assessment?

Correct Answer: D

Rationale: Tube patency should be checked prior to all feedings. The feeding should not be attempted if the tube is not patent.

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