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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.
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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.
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 preparing a client for surgery. The client expresses concern that someone might steal her purse during the procedure. Which of the following actions should the nurse take?
- A. Offer to store the purse at the nurses' station.
- B. Tell the client to leave her purse in a drawer of the bedside table.
- C. Place the purse in the clothing bag with the client's other belongings.
- D. Offer to place the purse in the facility safe.
Correct Answer: D
Rationale: The correct answer is D: Offer to place the purse in the facility safe. This is the best option as it ensures the client's belongings are kept secure during the surgery. Storing the purse at the nurses' station (A) may not guarantee its safety. Leaving the purse in a drawer (B) or clothing bag (C) can also pose a risk of theft. Placing it in the facility safe (D) is the most secure and professional solution to address the client's concern.
Exhibit 1 Nurses' Notes 1315:
Client is postoperative following an open cholecystectomy, Client's partner is at bedside. Surgical dressing intact, with small amount of serosanguineous drainage on dressings. Client reports pain as 5 on a scale of 0 to 10. Client requests a dose of their pain medication. Client expresses concern regarding the cost of prescription medications. Client reports being unable to find transportation to follow-up appointment
Plan of Care
1300:
Case management referral for discharge planning.
Client will need home health referral for dressing changes Client to follow up with the provider at the clinic in 1 week.
A nurse case manager is reviewing the electronic medical record of a postoperative client. Click to highlight the findings that require follow-up by the case manager.
- A. Client reports being unable to find transportation to follow-up appointment
- B. Client expresses concern regarding the cost of prescription medications
- C. Case management referral for discharge planning
- D. Client will need home health referral for dressing changes
Correct Answer: A
Rationale: []
Rationale:
- Correct Answer (A): The client reporting being unable to find transportation to the follow-up appointment is a critical issue that requires immediate follow-up by the case manager to ensure continuity of care and adherence to the treatment plan.
- Incorrect Answer (B): Although concerns about the cost of prescription medications are important, they do not directly relate to the immediate follow-up needed postoperatively.
- Incorrect Answer (C): Case management referral for discharge planning is essential but does not specifically address the immediate follow-up after the postoperative period.
- Incorrect Answer (D): While the client needing a home health referral for dressing changes is important, it does not pertain to the immediate follow-up that the case manager needs to address.
A nurse preceptor is observing a newly hired nurse perform a sterile dressing change. Which of the following actions should the nurse preceptor identify as maintaining sterile technique?
- A. Uses a sterile-gloved hand to adjust the back of the sterile gown
- B. Uses sterile forceps to pack sterile gauze into the wound
- C. Places sterile gauze 1.3 cm (0.5 in) away from the edge of a sterile drape
- D. Sets up the sterile field 30 min prior to performing the dressing change
Correct Answer: B
Rationale: Using sterile forceps to pack gauze maintains sterility, reducing infection risk, unlike actions that breach sterile field integrity.