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The nurse is caring for a client who has been brought to the emergency department after a severe car accident. They require immediate life-saving surgery; however, they are unconscious and unable to consent to the operation. Which of the following is the best course of action?
- A. Ask a friend who was with the client to sign the consent form.
- B. Attempt calling a family member to obtain consent.
- C. Call the on-staff nursing supervisor and request a court order for the surgery.
- D. Immediately transport the client to the operating department without obtaining consent.
Correct Answer: D
Rationale: Implied consent applies for unconscious clients needing life-saving surgery (D), allowing immediate transport to the operating room. Friends (A) cannot legally consent, family contact (B) delays care, and court orders (C) are unnecessary in emergencies.
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The nurse is conducting a teaching session with the parents of a child newly diagnosed with asthma. The priority topic for the nurse to cover is
- A. how to use a peak flow meter.
- B. signs and symptoms of an asthma attack.
- C. the need to stay current with immunizations.
- D. community resources available for asthma management.
Correct Answer: B
Rationale: Recognizing signs and symptoms of an asthma attack (B) is critical for parents to initiate prompt intervention, preventing severe exacerbations. Peak flow meter use (A), immunizations (C), and community resources (D) are important but secondary to immediate safety education.
A nurse is delegating tasks to the unlicensed assistive personnel (UAP). Which task is most appropriate for the UAP to perform?
- A. Assisting a client with dysphagia during oral feedings.
- B. Documenting a client’s response to a medication administered for pain relief.
- C. Collecting a clean-catch urine sample from a client.
- D. Removing a client’s indwelling urinary catheter per the provider’s order.
Correct Answer: C
Rationale: Collecting a clean-catch urine sample (C) is a non-invasive task within the UAP’s scope. Feeding with dysphagia (A), documenting medication response (B), and catheter removal (D) require clinical judgment or training beyond UAP scope.
The nurse is caring for a newly admitted client. Which task can the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Apply nasal cannula oxygen
- B. Remove a vascular access device that is not patent
- C. Perform venipuncture for laboratory work
- D. Obtain vital signs every four hours
Correct Answer: D
Rationale: Obtaining vital signs every four hours (D) is a routine task within the UAP’s scope. Applying oxygen (A), removing vascular access (B), and venipuncture (C) require nursing skills and judgment.
A nurse is caring for four clients on a medical-surgical unit. Which client should the nurse assess first?
- A. A client with a blood glucose of 250 mg/dL [70–100 mg/dL, 4.0–5.6 mmol/L] who is requesting insulin coverage.
- B. A client post-thyroidectomy with a hoarse voice and difficulty speaking.
- C. A client with pneumonia reporting shortness of breath after ambulating.
- D. A client post-cholecystectomy requesting pain medication for a pain score of 7/10 on the Numerical Rating Scale.
Correct Answer: B
Rationale: Hoarse voice and difficulty speaking post-thyroidectomy (B) suggest possible laryngeal nerve damage or hypocalcemia, life-threatening complications requiring immediate assessment. High glucose (A), shortness of breath (C), and pain (D) are less acute.
The nurse is planning client assignments in the mental health unit. Which task should the nurse delegate to the licensed practical/vocational nurse (LPN/VN)?
- A. conduct a suicide assessment on a newly admitted client
- B. administering prescribed lithium to a client with bipolar disorder
- C. leading a group therapy session for clients with depressive disorders
- D. monitoring a client who is talking on the phone to a family member
Correct Answer: B
Rationale: Administering prescribed lithium (B) is within the LPN’s scope, involving medication administration to a stable client. Suicide assessment (A) and group therapy (B) require RN expertise, and monitoring phone calls (C) is a UAP task, making these inappropriate for LPN delegation (D).