Nokea
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.
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A nurse enters a client's room and notices a small fire in the bathroom trash can. The nurse removes the client from the room. Which of the following actions should the nurse take next?
- A. Activate the fire alarm.
- B. Close the fire doors and the doors to the clients' rooms.
- C. Remove all clients from the unit.
- D. Extinguish the fire.
Correct Answer: A
Rationale: The correct answer is A: Activate the fire alarm. This is the most critical step as it alerts others in the facility to the fire, ensuring swift evacuation and response from the fire department. Closing fire doors (choice B) and removing all clients from the unit (choice C) are important steps but should be done after the fire alarm is activated. Attempting to extinguish the fire (choice D) before ensuring everyone's safety is not recommended as it can put the nurse and clients at risk.
A nurse is caring for a client who is scheduled for placement of a central venous access device. Which of the following actions is the nurse's responsibility in the informed consent process?
- A. Assess the client's understanding after the provider has talked with her.
- B. Discuss alternative treatment options with the client.
- C. Review the risks and benefits of the procedure with the client.
- D. Place a photocopy of the signed informed consent in the client's medical record.
Correct Answer: A
Rationale: Correct answer: A
Rationale: The nurse's responsibility in the informed consent process is to assess the client's understanding after the provider has discussed the procedure with the client. This step ensures that the client has comprehended the information provided by the provider, clarifies any uncertainties, and confirms the client's voluntary agreement to the procedure. It is crucial for the nurse to confirm the client's understanding to uphold the principles of autonomy and informed decision-making in healthcare.
Summary of other choices:
B: Discussing alternative treatment options is a responsibility of the provider, not the nurse in the informed consent process.
C: Reviewing risks and benefits of the procedure is typically done by the provider during the informed consent process.
D: Placing a photocopy of the signed informed consent in the client's medical record is important but does not directly involve the nurse's role in the informed consent process.
A nurse is caring for a client who has uterine prolapse. The provider has recommended a total abdominal hysterectomy, but the client tells the nurse that the surgery is not an option. Which of the following is an appropriate action for the nurse to take?
- A. Discuss with the client her concerns regarding the procedure.
- B. Initiate a mental health consult to determine the client's reasons for refusing surgery.
- C. Provide the client with information on treatment options and outcomes.
- D. Inform the client of the consequences of uterine prolapse and the need for intervention.
Correct Answer: A
Rationale: Correct Answer: A: Discuss with the client her concerns regarding the procedure.
Rationale:
1. Building Trust: By discussing the client's concerns, the nurse shows empathy and builds trust.
2. Client Autonomy: Respecting the client's decision-making process is essential.
3. Informed Decision-Making: Understanding the client's fears helps in providing tailored information.
4. Collaboration: Discussing concerns opens the door for shared decision-making.
5. Holistic Care: Addressing emotional aspects is crucial for overall well-being.
Incorrect Choices:
- B: Initiating a mental health consult may be premature and could undermine the client's autonomy.
- C: Providing information without addressing concerns may not address the root of the refusal.
- D: Informing the client without understanding her perspective may lead to increased anxiety and resistance.
A nurse is reviewing the plan of care for a child who has oppositional defiant disorder. Which of the following members of the interprofessional health care team should the nurse plan to consult?
- A. Physical therapist
- B. Social worker
- C. Occupational therapist
- D. Speech pathologist
Correct Answer: B
Rationale: The correct answer is B: Social worker. A social worker is essential in addressing the psychosocial aspects of oppositional defiant disorder, providing support to the child and family, and coordinating resources. Physical therapist (A) focuses on physical rehabilitation, occupational therapist (C) on activities of daily living, and speech pathologist (D) on communication issues, which are not the primary concerns in oppositional defiant disorder.
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.