Nokea
A nurse is caring for four clients. For which of the following clients should the nurse collaborate with the facility ethics committee?
- A. A young adult client who is participating in a medical research study
- B. A middle adult client who leaves the facility against medical advice
- C. An adolescent client whose parents refuse a blood transfusion for religious reasons.
- D. An older adult client who has advance directives on file
Correct Answer: C
Rationale: Parental refusal of a blood transfusion for a minor creates an ethical dilemma, balancing autonomy and the minor's health, requiring ethics committee input.
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The family members of an older adult client are expressing conflict over whether the client should have surgery that is recommended by the provider. The oldest adult child has durable power of attorney for health care for the client. The client is oriented to person, place, and time. Which of the following people has the legal authority to make this health care decision?
- A. The client
- B. The partner
- C. The provider
- D. The oldest adult child
Correct Answer: A
Rationale: A mentally competent client retains legal authority to make healthcare decisions, despite a durable power of attorney, which only applies when the client is incapacitated.
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 manager is reviewing isolation guidelines with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding of isolation guidelines?
- A. I will instruct visitors to wear a mask when visiting a client who is on contact precautions.
- B. I will have a client who is on airborne precautions wear a mask when out of her room.
- C. I will wear an N95 respirator mask when caring for a client who is on droplet precautions.
- D. I will place a client who has compromised immunity in a negative-pressure airflow room.
Correct Answer: B
Rationale: The correct answer is B because it demonstrates understanding of airborne precautions. Airborne precautions require clients to wear a mask when leaving their room to prevent the spread of infectious agents through the air. This statement aligns with the principle of protecting others from exposure.
Explanation for other choices:
A - Incorrect: Visitors, not clients, should wear masks on contact precautions to prevent the spread of infection to the client.
C - Incorrect: N95 respirator masks are used for airborne precautions, not droplet precautions.
D - Incorrect: Negative-pressure airflow rooms are used for clients on airborne precautions, not those with compromised immunity.
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.