Nokea
A client has refused a prescribed injection of subcutaneous heparin. Which initial action should the nurse take?
- A. Document the refusal
- B. Notify the primary healthcare provider (PHCP)
- C. Review the client's most recent platelet count
- D. Inquire with the client about the refusal
Correct Answer: D
Rationale: Inquiring about the refusal (D) allows the nurse to understand the client’s concerns, provide education, and address barriers, promoting informed decision-making. Documenting (A) and notifying the provider (B) are secondary steps, and reviewing platelet count (C) is irrelevant without addressing the refusal first.
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The nurse is caring for the following assigned clients. It would be a priority to follow up with a client who
- A. has atrial fibrillation and a heart rate of 112/minute.
- B. has glomerulonephritis with a blood pressure of 137/86 mm Hg.
- C. is receiving amphotericin B, and the most recent temperature is 100.4°F (38°C).
- D. has chronic obstructive pulmonary disease (COPD) with an oxygen saturation of 91% on room air.
Correct Answer: A
Rationale: Atrial fibrillation with a heart rate of 112/minute (A) indicates a rapid ventricular response, risking hemodynamic instability or stroke, requiring immediate rate control. Glomerulonephritis with normal BP (B), mild fever with amphotericin (C), and COPD with 91% saturation (D) are less urgent, as they are stable or expected.
The nurse has attended a staff education program about sources of negligent lawsuits. It would indicate effective understanding if the nurse identifies which of the following is a source of a negligent lawsuit?
- A. The nurse documents care under another nurse's username and password
- B. The nurse takes pictures of a client's medical record and distributes them online
- C. The nurse does not notify the physician of a client's critical laboratory result
- D. The nurse treats their spouse in the acute care facility with prescribed medications
Correct Answer: A, B, C, D
Rationale: All options (A, B, C, D) are sources of negligent lawsuits: documenting under another’s credentials (A) is fraudulent, sharing medical records online (B) violates HIPAA, failing to report critical results (C) delays care, and treating a spouse with medications (D) breaches professional boundaries and scope of practice. Since the question implies multiple selections, all are correct.
Which of the following is the first nursing action for a patient experiencing dyspnea?
- A. Remove pillows from under the patient's head
- B. Elevate the head of the bed
- C. Elevate the foot of the bed
- D. Take the patient's blood pressure
Correct Answer: B
Rationale: Elevating the head of the bed (B) is the first action for dyspnea to improve lung expansion and ease breathing. Removing pillows (A) may worsen discomfort, elevating the foot (C) is irrelevant, and taking blood pressure (D) is secondary.
The nurse is witnessing a client provide informed consent. The client is demonstrating which ethical principle?
- A. Autonomy
- B. Justice
- C. Paternalism
- D. Veracity
Correct Answer: A
Rationale: Informed consent demonstrates autonomy (A), allowing the client to make self-determined decisions, per ethical principles. Justice (B) ensures fairness, paternalism (C) involves decision-making for the client, and veracity (D) is truth-telling, none central to consent.
The nurse is triaging phone calls at the physician’s office. The nurse should initially follow-up on the client who had
- A. cataract lens extraction one day ago and is reporting persistent nausea and vomiting.
- B. laparoscopic hysterectomy two days ago and is reporting pain with urination.
- C. ileostomy placement three days ago and is reporting that the stoma is swollen.
- D. total hip arthroplasty four days ago and refused physical therapy due to increased pain.
Correct Answer: A
Rationale: Persistent nausea and vomiting post-cataract surgery (A) suggest possible complications like increased intraocular pressure, requiring immediate follow-up. Dysuria (B), stoma swelling (C), and therapy refusal (D) are less urgent, as they are common or non-emergent.