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A nurse is caring for a client who is refusing a blood transfusion due to religious beliefs. Which of the following actions should the nurse take?
- A. Administer the transfusion after obtaining a court order.
- B. Document the client's refusal and inform the provider.
- C. Convince the client to accept the transfusion for their health.
- D. Ask the client's family to persuade the client.
Correct Answer: B
Rationale: Documenting the refusal and informing the provider respects the client's autonomy and ensures appropriate follow-up, while adhering to ethical and legal standards.
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A nurse in the emergency department is caring for a client who has a compression fracture of a spinal vertebra. During transport to the facility, the client was medicated with intravenous morphine. On arrival, the neurosurgeon determined urgent surgical intervention is indicated for the fracture. Staff members have been unable to reach the client's family. Which of the following actions should the nurse anticipate the neurosurgeon taking?
- A. Prescribing naloxone to reverse the effects of the morphine
- B. Asking the client to sign the surgical consent form
- C. Delaying the surgery until a member of the client's family is reached
- D. Invoking implied consent
Correct Answer: D
Rationale: The correct answer is D: Invoking implied consent. Implied consent allows healthcare providers to proceed with urgent treatment when a patient is unable to provide informed consent and there is an immediate threat to the patient's life or health. In this scenario, the client requires urgent surgical intervention for a compression fracture, and the family cannot be reached. Therefore, the neurosurgeon may invoke implied consent to proceed with the surgery to prevent further harm to the client.
A: Prescribing naloxone to reverse the effects of the morphine is not necessary in this case as the morphine was given for pain management and does not interfere with the need for urgent surgical intervention.
B: Asking the client to sign the surgical consent form is not appropriate as the client may not be in a condition to provide informed consent due to the urgent nature of the surgery and the effects of the medication.
C: Delaying the surgery until a member of the client's family is reached may not be feasible if there
A charge nurse is working with an assistive personnel (AP) who provides excellent care to clients and is an effective team member. Which of the following actions should the nurse take first to recognize the AP's contributions to client care?
- A. Tell other nurses what an effective team member the AP is.
- B. Detail the AP's contributions to the nurse manager.
- C. Nominate the AP for the Employee of the Month award.
- D. Give positive feedback directly to the AP.
Correct Answer: D
Rationale: The correct answer is D: Give positive feedback directly to the AP. This is the first action the nurse should take because it directly acknowledges and reinforces the AP's contributions. Providing feedback directly shows appreciation and motivates the AP to continue their excellent work. It helps build a positive relationship and boosts morale.
Choice A is less effective as it does not directly recognize the AP's efforts and may not reach the AP. Choice B involves an intermediary and may delay recognition. Choice C is a formal recognition and may not provide immediate feedback to the AP. Thus, giving direct positive feedback to the AP is the most immediate and impactful way to recognize their contributions.
A charge nurse is evaluating the performance of an assistive personnel (AP). Which of the following actions by the AP indicates a need for further education?
- A. The AP reports a client's temperature of 38.5°C to the nurse.
- B. The AP assists a client with turning every 2 hours.
- C. The AP leaves a client's meal tray out of reach after delivery.
- D. The AP uses a gait belt when ambulating a client.
Correct Answer: C
Rationale: Leaving the meal tray out of reach prevents the client from eating, indicating a need for further education on client-centered care. The other actions are appropriate.
A nurse is preparing to delegate tasks to a licensed practical nurse (LPN). Which of the following tasks is appropriate for the LPN to perform?
- A. Develop a care plan for a client with a new diagnosis of diabetes.
- B. Administer a prescribed subcutaneous insulin injection.
- C. Perform an admission assessment for a client with chest pain.
- D. Evaluate the effectiveness of a client's pain management plan.
Correct Answer: B
Rationale: The correct answer is B: Administer a prescribed subcutaneous insulin injection. LPNs are trained to administer medications, including insulin injections, under the supervision of a registered nurse or physician. LPNs have the knowledge and skills necessary to safely administer medications. Choices A, C, and D involve assessments, evaluations, and care planning, which are tasks typically performed by registered nurses. LPNs can assist with these tasks but should not independently perform them. Overall, LPNs are best suited to carry out tasks related to direct patient care, such as medication administration.
A nurse and an assistive personnel (AP) are providing care for four clients who were admitted to the medical-surgical unit on the previous shift. The nurse should delegate meal assistance for which of the following clients to the AP?
- A. A client who has Guillain-Barre syndrome
- B. A client who has a lumbosacral spinal tumor
- C. A client who has systemic sclerosis
- D. A client who has amyotrophic lateral sclerosis (ALS)
Correct Answer: B
Rationale: The correct answer is B. A client with a lumbosacral spinal tumor may need assistance with meals due to potential mobility limitations or weakness. The nurse can delegate this task to the AP as it falls within their scope of practice. Clients with Guillain-Barre syndrome (choice A) may have muscle weakness and difficulty swallowing, requiring skilled nursing assessment during mealtime. Clients with systemic sclerosis (choice C) may have gastrointestinal involvement, necessitating careful monitoring during meals. Clients with ALS (choice D) have progressive muscle weakness, making it crucial for a nurse to assess their ability to eat safely. Delegating meal assistance for these clients to an AP may compromise their safety.