Nokea
A client with terminal cancer becomes hypoxic and unresponsive. According to the client’s paperwork, the client’s sister is the legal medical power of attorney. Both the client’s spouse and sister are present. Which action by the nurse is appropriate at this time?
- A. Ask the spouse about the client’s wishes
- B. Get directions about care from the client’s sister
- C. Prepare for emergency intubation
- D. Request that the sister provide a living will
Correct Answer: B
Rationale: The sister, as the legal medical power of attorney, is authorized to make healthcare decisions when the client is unresponsive. Consulting the spouse is inappropriate, intubation may not align with the client’s wishes, and a living will is not required as the sister has decision-making authority.
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The nurse has attended a staff education program about ethical practices in nursing. Which of the following statements by the nurse would indicate a correct understanding of the program? Select all that apply.
- A. Accountability is notifying the health care provider after making a medication error.
- B. Autonomy is informing the client of the care decisions the family has made for the client.
- C. Confidentiality is respecting a client's request to keep suicidal ideation a secret from other members of the health care team.
- D. Fidelity is returning to the client's room with pain medication at the time that was promised to the client.
- E. Nonmaleficence is reporting suspected elder abuse of a client with Alzheimer disease.
Correct Answer: A,D,E
Rationale: Accountability involves taking responsibility for errors (A). Fidelity is keeping promises, such as timely medication delivery (D). Nonmaleficence includes preventing harm by reporting abuse (E). Autonomy respects the client's decision-making, not family decisions (B), and confidentiality does not extend to withholding suicidal ideation, which requires intervention (C).
In an emergency situation, the nurse determines whether a client has an airway obstruction. Which of the following does the nurse assess?
- A. ability to speak
- B. ability to hear
- C. oxygen saturation
- D. adventitious breath sounds
Correct Answer: A
Rationale: Inability to speak is a primary indicator of airway obstruction, as it suggests blocked airflow. Hearing, oxygen saturation, and breath sounds are secondary or less immediate. Safety and Infection Control
The nurse is caring for a client with left ventricular heart failure. Which one of the following assessments is an early indication of inadequate oxygen transport?
- A. Crackles in the lungs
- B. Confusion and restlessness
- C. Distended neck veins
- D. Use of accessory muscles
Correct Answer: B
Rationale: Confusion and restlessness. Neurological changes, including impaired mental status, are early signs of inadequate oxygenation.
As part of a routine health screening, the nurse notes the play of a 2-year-old child. Which of the following is an example of age-appropriate play at this age?
- A. builds towers with several blocks
- B. tries to color within the lines
- C. says 'Mine!' when playing with toys
- D. tries to jump rope
Correct Answer: C
Rationale: Saying 'Mine!' reflects the possessive, independent behavior typical of 2-year-olds. The other activities are either too advanced or not age-specific. Health Promotion and Maintenance
How often must physical restraints be released?
- A. every 2 hours
- B. between 1 and 3 hours
- C. every 30 minutes
- D. at least every 4 hours
Correct Answer: A
Rationale: Physical restraints must be released every 2 hours to assess skin, circulation, and comfort, with checks every 30 minutes while restrained. Safety and Infection Control