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A nurse is teaching a client about implied consent. Which of the following information should the nurse include in the teaching?
- A. The nurse's signature indicates they witnessed the client's signature.
- B. A client must understand risks and benefits of the proposed treatment.
- C. Nonverbal behavior indicates agreement.
- D. Consent can be verbal or written.
Correct Answer: C
Rationale: Implied consent is inferred from nonverbal actions or circumstances, unlike express consent, which involves explicit verbal or written agreement.
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A nurse is caring for a client who is unconscious and whose partner is their health care surrogate. The partner wishes to discontinue the client's feeding tube, but another family member tells the nurse that they want the client to continue receiving treatment. Which of the following responses should the nurse make?
- A. We'll need to have the nursing supervisor review the client's advance directives.
- B. As the health care surrogate, the client's partner can make this decision.
- C. You should contact the provider about your wishes for your family member.
- D. You should speak with the facility's ethics committee about your concerns.
Correct Answer: B
Rationale: The correct answer is B: As the health care surrogate, the client's partner can make this decision. The rationale for this is that a health care surrogate is legally designated to make medical decisions on behalf of an incapacitated individual. In this case, since the client is unconscious, the partner's wishes as the surrogate should be followed.
Choice A is incorrect because involving the nursing supervisor to review advance directives is not necessary when a designated surrogate is involved. Choice C is incorrect as contacting the provider is not relevant when the surrogate has the legal authority to make decisions. Choice D is also incorrect as involving the ethics committee is not necessary when a surrogate has the authority to make decisions.
A nurse is caring for a client who has a new diagnosis of Crohn's disease and is interested in learning more about their condition. Which of the following actions should the nurse take?
- A. Encourage the client to research Crohn's disease on websites that have a gov address.
- B. Ask a licensed practical nurse to explain Crohn's disease to the client.
- C. Recommend podcasts that discuss Crohn's disease to the client.
- D. Suggest that the client read articles that recommend specific treatments for Crohn's disease.
Correct Answer: A
Rationale: The correct answer is A: Encourage the client to research Crohn's disease on websites that have a gov address. This option is the most appropriate because government websites provide reliable and evidence-based information on medical conditions. The client can access accurate and up-to-date information to better understand their condition.
Choice B is incorrect because a licensed practical nurse may not have the same level of expertise and resources as a government website. Choice C is incorrect as podcasts may not always provide detailed and accurate information. Choice D is incorrect because reading articles recommending specific treatments may not provide a comprehensive understanding of the disease itself. It is important for the client to have a solid foundation of knowledge about Crohn's disease before delving into treatment options.
A triage nurse in an emergency department is caring for a group of clients. Which of the following clients should the nurse assess first?
- A. A client who has a closed femur fracture from a fall
- B. A client who has a superficial burn covering 10% of their total body surface area
- C. A client who is experiencing severe vomiting and diarrhea with tachycardia
- D. A client who is confused and has slurred speech
Correct Answer: D
Rationale: Confusion and slurred speech suggest a possible stroke, a time-sensitive emergency requiring immediate assessment to optimize outcomes.
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 delegating client care. Which of the following tasks should the nurse delegate to assistive personnel?
- A. Instructing a client on self-administration of a tap water enema
- B. Suctioning a client's long-term tracheostomy
- C. Performing a dressing change on a client's peripherally inserted central catheter
- D. Using a pain rating scale to monitor a client's pain level
Correct Answer: D
Rationale: The correct answer is D: Using a pain rating scale to monitor a client's pain level. This task can be safely delegated to assistive personnel as it involves non-invasive monitoring that does not require specialized medical knowledge. Assistive personnel can accurately record the pain level reported by the patient without interpreting or making clinical decisions based on the information. In contrast, choices A, B, and C involve invasive procedures or specialized skills that require clinical judgment and assessment, making them inappropriate for delegation to assistive personnel. Choice D allows the nurse to focus on more complex nursing assessments and interventions while ensuring the client's pain is monitored effectively.