Nokea
The ICU nurse caring for a client who has just been declared brain dead can expect to find evidence of the client's wishes regarding organ donation:
- A. on the driver's license of the client.
- B. in the client's safety deposit box.
- C. in the client's last will and testament.
- D. on the client's insurance card.
Correct Answer: A
Rationale: In most states, indication of organ donor status is found on the driver's license. Evidence in a last will and testament or in a safety deposit box is not readily accessible for decision-making if the need arises. Insurance cards do not contain such information.
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The nurse and a colleague are on the elevator after their shift, and they hear a group of health caregivers discussing a recent client scenario. Which client right might be breached?
- A. right to refuse treatment
- B. right to continuity of care
- C. right to confidentiality
- D. right to reasonable responses to requests
Correct Answer: C
Rationale: The right to confidentiality of client information might be breached when client care situations are discussed in public areas or without regard to maintaining the information as private and confidential. The other rights listed have not been breached in this instance.
In what order should the LPN see the following clients? A. a 72-year-old client with pneumonia asking to order her dinner.,B. a 23-year-old client with left arm fracture after an MVA complaining of 6 out of 10 pain in his arm.,C. a 53-year-old client with lower leg swelling complaining of sudden onset headache and blurry vision. ,D. a 47-year-old client requesting more information regarding her surgery scheduled in three hours
- A. A) A, D, B, C
- B. B) C, B, D, A
- C. C) D, C, B, A
- D. D) B, C, A, D
Correct Answer: B
Rationale: Prioritizing client care is a critical skill to learn as a LPN. The 53-year-old is at highest risk for serious healthcare complications and should be seen first. The 23-year-old's pain should be addressed second, prior to answering questions about the 47-year-old's surgery. Finally, the LPN should address the needs of the 72-year-old client.
The nurse is caring for a client awaiting test results on a biopsy. The client is unconscious, and the physician informs the client's spouse that the biopsy came back positive for cancer. The spouse asks the nurse if they will not share this news with the client because they would prefer the client be unaware of the diagnosis. Which of the following responses is most appropriate?
- A. I will have a psychiatrist confirm that the news will cause negative effects, and if so, I will comply with your request.'
- B. For ethical reasons, I am unable to withhold this information from the client.'
- C. You will need to sign paperwork stating you are accepting the risk of not sharing this with the client.'
- D. You must have a durable power of attorney for health care advanced directive in place before I can consider this request.'
Correct Answer: B
Rationale: The ethical principle of veracity requires that the nurse is truthful with the client and does not withhold information even if it is requested by the family.
Which of the following tasks are appropriate for an LPN to perform?
- A. Adjust the cervical traction device of a 68-year-old client as instructed by the charge nurse.
- B. Teaching a 24-year-old first-time mother how to properly care for her new baby.
- C. Assess a 36-year-old man newly admitted for chest pain.
- D. Obtain an occult blood sample from a 16-year-old client with ulcerative colitis.
- E. Document the administration of acetaminophen to a 43-year-old, status post-op knee arthroplasty.
Correct Answer: A
Rationale: While LPNs are expected to perform assessments, initial assessments should always be performed by a registered nurse or attending physician. LPNs should take orders for client care and equipment adjustment from prescribing providers directly, not the charge nurse. Teaching, obtaining stool samples, and documenting medication administration are all within the scope of practice of an LPN.
While performing a physical assessment on a 6-month-old infant, the nurse observes head lag. Which of the following nursing actions should the nurse perform first?
- A. Ask the parents to allow the infant to lay on her stomach to promote muscle development
- B. Notify the physician because a developmental or neurological evaluation is indicated
- C. Document the findings as normal in the nurse's notes
- D. Explain to the parents that their child is likely to be mentally retarded
Correct Answer: B
Rationale: Persistent head lag at 6 months suggests developmental or neurological issues, warranting immediate physician referral for evaluation.