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The nurse has learned during nursing school to maintain honesty and openness with all clients, even when conveying potentially distressing information. This approach aligns with the ethical principle of
- A. beneficence.
- B. veracity.
- C. nonmaleficence.
- D. fidelity.
Correct Answer: B
Rationale: Honesty and openness (B) align with veracity, the ethical principle of truth-telling. Beneficence (A) promotes well-being, nonmaleficence (C) avoids harm, and fidelity (D) keeps promises, but veracity is most relevant here.
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The nurse is caring for a client who reports having a durable power of attorney. The nurse understands that this type of advance directive is
- A. a person who makes decisions for a client once the health care provider states the client no longer has the capacity to make their own health care decisions.
- B. a legal document that tells health care providers and family members about which life-sustaining treatment is wanted or unwanted if the client is unable to make decisions.
- C. a legal document in which a client designates someone else to make medical decisions for them when the client can no longer do so.
- D. a specific designation specifying who can receive and discuss the client's privileged healthcare information.
Correct Answer: C
Rationale: A durable power of attorney for healthcare (C) is a legal document designating a proxy to make medical decisions when the client is incapacitated. Option (A) describes the role, not the document. Option (B) describes a living will, and (D) refers to HIPAA authorization, not an advance directive.
The nurse reviews the client's emergency department (ED) triage note. Which action should the nurse take first? See the image below.
- A. Establish continuous cardiac monitoring
- B. Obtain an order for a complete metabolic panel
- C. Obtain a prescription for acetaminophen (APAP)
- D. Apply a cool compress to the client's forehead
Correct Answer: A
Rationale: This client is showing manifestations of digitalis toxicity. The client's bradycardia, anorexia, and vomiting are classic signs of this potentially fatal toxicity. The nurse should immediately establish continuous cardiac monitoring because, if untreated, digitalis toxicity may cause multifocal premature ventricular contractions (PVCs) that may transition to ventricular tachycardia or ventricular fibrillation. Because of digitalis' ability to have a negative chronotropic effect, bradycardia is often seen in toxicity.
A charge nurse is preparing client assignments for the shift. Which client is most appropriate to assign to a licensed practical/vocational nurse (LPN/VN)?
- A. A client with a chest tube requiring frequent oral suctioning.
- B. A client receiving continuous IV heparin for a pulmonary embolism (PE).
- C. A client 24 hours post-abdominal surgery requiring daily wound care.
- D. A client with new-onset seizures awaiting diagnostic tests.
Correct Answer: C
Rationale: A client 24 hours post-abdominal surgery needing wound care (C) is stable and within the LPN scope. Chest tube suctioning (A) and heparin infusion (B) require RN monitoring for complications. New-onset seizures (D) require RN assessment due to instability.
The registered nurse (RN) and licensed practical/vocational nurse (LPN/VN) are caring for a client with an infected leg ulcer. Which task should the RN delegate to the LPN/VN?
- A. Obtain wound cultures during dressing changes
- B. Teach the client about high-protein food choices
- C. Assess the risk for further skin breakdown
- D. Initiate an outpatient wound care referral
Correct Answer: A
Rationale: Obtaining wound cultures during dressing changes (A) is a technical task within the LPN’s scope. Teaching (B), risk assessment (C), and referral initiation (D) require RN-level judgment and education skills.
The nurse has several tasks that need to be completed. Which of the following client assignments would be appropriate to delegate to the unlicensed assistive personnel?
- A. A 65-year-old male requiring sterile dressing changes.
- B. A 26-year-old female requiring a one-person assist in ambulating to the restroom.
- C. An 80-year-old male who is receiving enteral feedings continuously through an NG tube.
- D. A 23-year-old client requiring frequent urinary specimen collections from their indwelling urinary catheter.
Correct Answer: B
Rationale: Assisting a client with ambulation (B) is a non-clinical task within the UAP’s scope. Sterile dressing changes (A), enteral feedings (C), and catheter specimen collection (D) require clinical judgment or training beyond UAP scope.