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A male client who fell at home and experienced a brief loss of consciousness becomes increasingly confused after admission to the medical unit. The family requests an update on the client's condition. Using the SBAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first?
- A. Increasing confusion of the client.
- B. Client's healthcare power of attorney.
- C. Currently prescribed medications.
- D. Fall at home as reason for admission.
Correct Answer: A
Rationale: The current situation (increasing confusion) is the first step in SBAR, addressing the family's immediate concern. Power of attorney, medications, and fall history are provided later in the communication.
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A client with life-threatening injuries from a gunshot wound to the abdomen is mechanically ventilated and sedated. The client has a large family present who are asking multiple and repetitive questions. Which intervention should the nurse implement first?
- A. Let each family member ask a question one at a time.
- B. Request the healthcare provider to speak with the family.
- C. Ask the family to identify a specific spokesperson.
- D. Page a chaplain on call to be present for questions.
Correct Answer: C
Rationale: Designating a spokesperson streamlines communication, reducing repetitive questions and respecting client privacy. Individual questioning, provider involvement, or chaplain support are less immediate solutions.
A client is admitted with shortness of breath and hemoptysis. After several tests, the healthcare provider informs the client that the medical diagnosis is stage 4 breast cancer. The client tells the nurse about the decision not to inform the family about the diagnosis. Which intervention should the nurse implement?
- A. Notify the health department of the client's condition.
- B. Advise the client to weigh all possible outcomes prior to the decision.
- C. Suggest to the family the value of genetic screening.
- D. Explain that the family has a right to know of potential health problems.
Correct Answer: B
Rationale: Advising the client to consider outcomes respects her autonomy while encouraging informed decision-making. Notifying the health department, suggesting screening, or asserting family rights violate confidentiality or autonomy.
To help prevent by a dissatisfied client, which objective is most important to include in the orientation classes for staff nurses? New nursing staff members will
- A. demonstrate how to complete an adverse occurrence or variance report.
- B. discuss how to handle complaints from clients and/or their families.
- C. describe how to obtain legal services if needed.
- D. maintain personal malpractice insurance.
Correct Answer: B
Rationale: Teaching nurses to handle complaints effectively can prevent escalation to litigation by resolving conflicts early. Completing variance reports, obtaining legal services, or maintaining insurance are important but less preventive than addressing complaints directly.
An adult woman with metastatic pancreatic cancer has requested that no heroic measures are implemented to save her life. Instructions from the healthcare provider have been received to transfer the client to a palliative care room. Which action is most important for the nurse to take first?
- A. Ensure transfer of the client's electronic chart code.
- B. Give a detailed report to the accepting nurse.
- C. Take the family to the client's new room.
- D. Give the client written information about end-of-life care.
Correct Answer: B
Rationale: Giving a detailed report ensures continuity of care, critical for the client's palliative needs. Transferring chart codes, escorting family, or providing written information are secondary to effective handoff.
The home health aide caring for a home bound hospice client calls to inform the nurse that the client has reported feeling constipated. Which task should the nurse instruct the home health aide to perform?
- A. Listen for the presence of bowel sounds.
- B. Teach the client about foods high in fiber.
- C. Administer a prescribed dose of a laxative.
- D. Assist the client in drinking warm prune juice.
Correct Answer: D
Rationale: Assisting with drinking warm prune juice is within the aide's scope and promotes natural relief of constipation. Listening for bowel sounds, teaching about fiber, and administering laxatives require nursing skills and are beyond the aide's role.