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?

Correct Answer: B

Rationale: The correct answer is B: 'What do you think your spouse would have wanted?' Rationale: 1. This response shows empathy and respect for the spouse's feelings and autonomy. 2. It allows the spouse to reflect on the wishes and values of the brain-dead client. 3. It helps the spouse make a decision based on what the client would have wanted, rather than external pressures. Incorrect choices: A: A shortage of organs is not a valid reason to pressure the spouse into donating organs. C: Bringing up religion may only add unnecessary complexity to an already difficult decision. D: Emphasizing personal feelings may guilt-trip the spouse into making a decision that may not align with the client's wishes.

Correct Answer: D

Rationale: The correct answer is D: Nonmaleficence. The nurse is upholding the principle of nonmaleficence by protecting the surgeon's right to privacy and confidentiality. By not disclosing the surgeon's medical diagnosis to another nurse, the nurse is preventing potential harm or breach of confidentiality. This demonstrates respect for the surgeon's autonomy and right to confidentiality. Summary: A: Utility - Not relevant in this scenario, as it pertains to maximizing benefits and minimizing harms for the majority. B: Paternalism - Not applicable here, as it involves making decisions for someone else's benefit without their consent. C: Justice - Not applicable in this context, as it relates to fairness and equitable distribution of resources or benefits.

Correct Answer: C

Rationale: The correct answer is C. The nurse should care for the client asking about his PCA pump containing morphine first because it involves a critical aspect of pain management. Morphine is a potent opioid that requires careful monitoring to prevent adverse effects like respiratory depression. Addressing the client's concerns promptly ensures safe and effective pain management. Choice A is incorrect because assisting with a bath is important but not as urgent as addressing a client's pain management needs. Choice B is incorrect as the client requesting a referral for home health services can wait as it is not an immediate health concern. Choice D is incorrect as addressing questions about a new prescription can be done after ensuring the client's immediate health needs are met.

Correct Answer: D

Rationale: The correct answer is D: Nonmaleficence. Nonmaleficence is the ethical principle of doing no harm. In this scenario, discontinuing the experimental chemotherapy medication after evidence of rapidly advancing kidney failure is in line with this principle. Continuing the medication would harm the client further, so stopping it is the right course of action. Incorrect choices: A: Veracity - Veracity is the principle of truth-telling. Stopping the medication is not related to truth-telling. B: Autonomy - Autonomy is the principle of respecting the client's right to make their own decisions. Stopping the medication for the client's safety is not against their autonomy. C: Fidelity - Fidelity is the principle of keeping promises. Stopping the medication does not violate any promises made to the client.

Correct Answer: B

Rationale: The correct answer is B because fluctuating blood pressure and pulse indicate a potential unstable condition requiring close monitoring and immediate intervention, necessitating the oncoming nurse to assume total care. A: Family presence doesn't necessarily indicate the need for total care. C: Past thoughts of suicide require assessment and monitoring, but not necessarily total care. D: Client's job is irrelevant to the current care needs and doesn't mandate total care assumption.