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A nurse in the emergency department is preparing to care for a client who arrived via ambulance. The client is disoriented and has a cardiac arrhythmia. Which of the following actions should the nurse take?
- A. Contact the client's next of kin to obtain consent for treatment.
- B. Notify risk management before initiating treatment.
- C. Have the client sign a consent for treatment.
- D. Proceed with treatment without obtaining written consent
Correct Answer: D
Rationale: The correct answer is D: Proceed with treatment without obtaining written consent. In emergency situations, the priority is providing immediate care to stabilize the client's condition. Obtaining written consent can delay treatment, which could be life-threatening for the client. Contacting next of kin (A), notifying risk management (B), and having the client sign a consent form (C) are not appropriate in this critical situation as they all involve unnecessary steps that could compromise the client's health. The nurse's primary responsibility is to ensure the client's safety and well-being by promptly addressing the cardiac arrhythmia.
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A charge nurse is receiving change-of-shift report. Which of the following situations should the charge nurse address first?
- A. The emergency department nurse is waiting to give report on a new admission.
- B. Two staff members have called to say they will be absent.
- C. A nurse on the previous shift wrote an incident report about a medication error.
- D. Transport assistance is unavailable to take a client to occupational therapy.
Correct Answer: A
Rationale: The correct answer is A because the charge nurse should address urgent situations first. The emergency department nurse waiting to give report on a new admission indicates a critical patient needing immediate attention. Addressing this first ensures timely and appropriate care for the patient. Choices B and D, staff absences and transport assistance availability, can be managed after addressing the urgent patient situation. Choice C, the incident report about a medication error, is important but not as time-sensitive as the new admission report. Therefore, the charge nurse should prioritize addressing the emergency department nurse's report first.
A nurse is providing discharge teaching to the parent of a toddler who has a new diagnosis of asthma. The parent states she is unable to afford the nebulizer prescribed for the child. Which of the following referrals should the nurse recommend?
- A. Pharmacist
- B. Respiratory therapist
- C. Social worker
- D. Child protective services
Correct Answer: C
Rationale: A social worker can connect the family with financial resources to obtain the nebulizer, addressing the affordability issue.
A nurse on a medical-surgical unit is caring for four clients. The nurse should recognize that which of the following clients is the highest priority?
- A. A client who has peripheral vascular disease and has an absent pedal pulse in the right foot
- B. A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary temperature of 38° C (101° F)
- C. A client who is postoperative following a laminectomy 12 hr ago and is unable to void
- D. A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV chemotherapy
Correct Answer: A
Rationale: An absent pedal pulse indicates a critical circulatory issue, potentially limb-threatening, requiring immediate attention over other less urgent conditions.
A nurse is assessing a client who had a stroke 2 days ago. Which of the following findings should the nurse identify as a need for a referral to speech-language pathology?
- A. Diminished hand-to-mouth coordination
- B. Impaired voluntary cough
- C. Unilateral ptosis
- D. Altered level of consciousness
Correct Answer: B
Rationale: The correct answer is B: Impaired voluntary cough. Impaired voluntary cough in a client who had a stroke can indicate dysphagia, which is a common complication post-stroke. Referral to speech-language pathology is essential for assessing and managing dysphagia to prevent aspiration pneumonia and malnutrition. Diminished hand-to-mouth coordination (A) may indicate motor deficits but does not directly relate to speech and swallowing. Unilateral ptosis (C) is a drooping eyelid and is not typically a direct concern for speech-language pathology. Altered level of consciousness (D) may indicate neurological issues but does not specifically warrant a referral to speech-language pathology.
A nurse is conducting an in-service on client advocacy with a group of newly licensed nurses. Which of the following scenarios should the nurse include as examples of client advocacy?
- A. Implementing a client's plan of care based upon nursing goals
- B. Obtaining an interpreter for a client who speaks a different language than the nurse
- C. Documenting a client's refusal to take a prescribed medication
- D. Initiating IV access on a client who has dementia while he is sleeping
- E. Providing written information to a client regarding palliative care
Correct Answer: B,C,E
Rationale: The correct scenarios for client advocacy are B: Obtaining an interpreter for a client who speaks a different language than the nurse, C: Documenting a client's refusal to take a prescribed medication, and E: Providing written information to a client regarding palliative care.
B is correct as it ensures effective communication, promoting the client's understanding and autonomy. C is essential for respecting the client's right to make decisions about their care. E demonstrates advocacy by empowering the client with information about their care options.
A is incorrect as it focuses on the nurse's goals rather than the client's needs. D is inappropriate as it violates the client's rights by performing a procedure without consent.
In summary, client advocacy involves respecting autonomy, ensuring effective communication, and providing information to empower the client in decision-making.