Nokea
The nurse is caring for a client who is a Jehovah's Witness and is scheduled for hip replacement surgery. The client refuses to sign consent for blood due to religious reasons. The client's daughter has the power of attorney in case the client is unable to state his wishes regarding health care. The daughter tells the nurse, 'I'm afraid if something goes wrong, dad might need blood. I want to sign a blood consent form since I'm his power of attorney.' The daughter is not a Jehovah's Witness. Which action by the nurse is the best in this situation?
- A. notify the charge nurse so that she can ask the night shift nurse to handle the situation
- B. go and get a blood consent form for the daughter to sign, noting that she has power of attorney over the client
- C. notify the surgeon that the client's daughter has power of attorney and will be signing a blood consent form so that an order may be obtained for a type and cross
- D. remind the daughter that the client clearly does not wish to receive blood, and that a power of attorney cannot override client wishes that have been clearly stated when he was able to give or refuse consent
Correct Answer: D
Rationale: A power of attorney cannot override a competent client's clearly stated wishes, respecting autonomy and religious beliefs.
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The nurse is caring for a client with an infected leg wound. The client develops a fever of 102°F. Which action by the nurse is the priority for this client?
- A. obtain a wound culture
- B. administer acetaminophen
- C. administer IV antibiotic as scheduled
- D. perform the scheduled dressing change
Correct Answer: C
Rationale: Administering antibiotics addresses the infection, the likely cause of the fever, and is the priority.
The nurse notices an increase in the prevalence of deep vein thrombosis among clients in a surgical unit. The nurse collects data, develops a preventative program with peers, and works with her manager to implement a new policy and procedure. Which of the following best describes the nurse's actions?
- A. collaboration
- B. consultation
- C. informatics
- D. performance improvement
Correct Answer: D
Rationale: Developing and implementing a preventative program to reduce DVT is a performance improvement initiative.
The nurse is preparing to transfer a client from the ICU to the floor. Which of the following ensures continuity of care for the client? Select all that apply.
- A. using approved abbreviations in documenting care
- B. providing report on the client using standard hand-off reports
- C. informing the receiving nurse of pending lab results and when they are expected
- D. informing the receiving nurse of any care that needs to be done, such as bathing
- E. telling the receiving nurse that the family is demanding and asks too many questions
Correct Answer: B,C,D
Rationale: Standard hand-off reports (B), informing about pending lab results (C), and communicating care needs (D) ensure continuity of care. Approved abbreviations (A) are good practice but not specific to continuity, and sharing subjective opinions about the family (E) is unprofessional.
The nurse is working with an unlicensed assistive personnel (UAP) in the medical-surgical unit. Which client should be assigned to the UAP?
- A. a client with cervical cancer who has an internal radiation implant
- B. a client who is receiving blood as treatment for hypovolemic shock
- C. a client who had an abdominal wound dehiscence 24 hours earlier and requires dressing changes
- D. a client who is post-op day 2 following a laparoscopic hernia repair and gets up to the chair for meals
Correct Answer: D
Rationale: The stable post-op client requires basic assistance, suitable for a UAP. The other clients need skilled nursing due to radiation safety, transfusion monitoring, or complex wound care.