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: Correct Answer: B Rationale: 1. Asking the spouse what the brain-dead client would have wanted respects the client's autonomy and allows the family to make a decision in alignment with the client's wishes. 2. This approach considers the emotional and ethical aspects of organ donation, ensuring that the decision is not solely based on external factors or pressure. 3. It promotes shared decision-making and empowers the spouse to make a choice that reflects the client's values and beliefs. Summary: - Option A is incorrect as it uses guilt and societal pressure to influence the decision, which is not ethical. - Option C is incorrect as it dismisses the spouse's confusion and oversimplifies the issue by focusing solely on religious beliefs. - Option D is incorrect as it manipulates emotions and does not address the spouse's confusion or the client's wishes.

Correct Answer: A

Rationale: The correct answer is A: Call the emergency response team. In this situation, the nurse must prioritize the client's immediate medical needs over the family's request for a DNR order. By calling the emergency response team, the nurse initiates potentially life-saving resuscitative measures while respecting the client's best interest. Seeking help from the risk manager (B) or waiting for a stat DNR order from the provider (C) could result in unnecessary delays in providing critical care. Doing nothing and solely respecting the family's wishes (D) may go against the nurse's duty to act in the client's best interest in an emergency situation.

Correct Answer: C

Rationale: The correct answer is C. HICS stands for Hospital Incident Command System, which is a standardized system used for managing incidents or disasters in healthcare settings. Choice C is correct because HICS indeed identifies facility responsibilities and channels of reporting, ensuring clear communication and coordination during emergencies. A: This statement is incorrect because while HICS does involve resource management, it does not specifically ensure the availability of antibiotics and antidotes. B: This statement is incorrect as HICS focuses on establishing a clear command structure and roles rather than the disciplines of responders. D: This statement is incorrect because while HICS may involve requesting additional resources, its primary focus is on coordinating within the facility rather than bringing in external responders.

Correct Answer: D

Rationale: The correct answer is D because the client not receiving any medications is a critical issue that requires immediate follow-up to ensure the client's safety and well-being. A, B, and C are not urgent concerns and can be addressed by the nurse or PN at a later time. A is related to non-essential comfort, B is a common query about discharge, and C is about routine care already provided. Thus, D stands out as the most concerning statement that necessitates immediate attention.

Correct Answer: D

Rationale: The correct answer is D: Contact isolation. MRSA is primarily spread through direct contact with infected wounds or contaminated surfaces. Contact isolation is crucial to prevent transmission. Reverse isolation (A) is used to protect immunocompromised patients. Airborne precautions (B) are for diseases transmitted through droplets in the air. Standard precautions (C) are used for all patients to prevent the spread of infections, but specific isolation precautions like contact isolation are necessary for MRSA.