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The healthcare provider discusses with a male client the need for a cardiac catheterization, describes the risks and benefits of the procedure, and asks the nurse to have the client sign the consent form. When the nurse presents the consent form for signature, the client hesitates and asks the nurse how the wires will keep his heart going. Which action should the nurse take?
- A. Call the client's next of kin and have them provide verbal consent.
- B. Explain the procedure again in detail and clarify any misperceptions.
- C. Notify the healthcare provider of the client's lack of understanding.
- D. Postpone the procedure until the client understands the risks/benefits.
Correct Answer: C
Rationale: Notifying the provider ensures the client's misunderstanding is addressed for valid informed consent.
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The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which activity should the nurse assign to the PN?
- A. Evaluate and update plans of care for clients.
- B. Complete comprehensive assessments.
- C. Determine the need for urinary catheterizations.
- D. Measure preoperative clients for elastic stocking size.
Correct Answer: C
Rationale: Determining the need for catheterizations is within the PN's scope, requiring clinical judgment suitable for their training.
The nurse observes a practical nurse (PN) placing a client on the right side with the left leg bent in preparation for a lumbar puncture. Which action should the nurse implement?
- A. Assume care of the client and assign the PN to the care of a different client.
- B. Acknowledge that the PN has positioned the client safely and correctly.
- C. Arrange for an unlicensed assistive personnel to assist the PN during the procedure.
- D. Demonstrate to the PN how to position the client more effectively for the procedure.
Correct Answer: D
Rationale: Demonstrating proper positioning corrects the error, educates the PN, and ensures client safety during the procedure.
Several family members are visiting a client who had a myocardial infarction 4 days ago. The unlicensed assistive personnel (UAP) informs the nurse that one of the visitors is lying on the client's bed. Which action should the nurse implement?
- A. Discuss why visitors should not lie in the bed with the client.
- B. Notify the charge nurse that the visitor is lying on the client's bed.
- C. Explain that the client has the right to have a visitor lie on the bed.
- D. Instruct the UAP to ask the visitor to get off the client's bed.
Correct Answer: D
Rationale: Instructing the UAP to address the visitor maintains hygiene and safety efficiently.
The healthcare provider prescribes an oral medication to be given daily for 3 days. However, the medication was also given on the fourth day. Which intervention is most important for the charge nurse to implement?
- A. Review the medication transcription with the nurse.
- B. Evaluate the client for symptoms of a drug interaction.
- C. Report the medication error to the nursing supervisor.
- D. Inform the pharmacist who dispensed the medication.
Correct Answer: C
Rationale: Reporting the error ensures proper documentation and follow-up for client safety.
The home health aide caring for a homebound hospice client calls to inform the nurse that the client has reported feeling constipated. Which task should the nurse instruct the home health aide to perform?
- A. Listen for the presence of bowel sounds.
- B. Administer a prescribed dose of a laxative.
- C. Teach the client about foods high in fiber.
- D. Assist the client to drink warm prune juice.
Correct Answer: D
Rationale: Assisting with warm prune juice is a safe, simple task within the aide's scope to relieve constipation.