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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.
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The nurse is teaching a group of students about incident reports. Which of the following situations would require an incident report? A visitor. Select all that apply.
- A. refusing to wear personal protective equipment (PPE).
- B. adjusting a client's infusion pump.
- C. requesting that their family member get pain medication.
- D. assisting their family member with brushing their teeth.
- E. stating that they fell while using the bathroom.
Correct Answer: A, B, E
Rationale: Refusing PPE (A), adjusting an infusion pump (B), and falling in the bathroom (E) are safety incidents requiring reports, as they pose risks or indicate harm. Requesting pain medication (C) and assisting with tooth brushing (D) are not reportable unless escalated.
The nurse is caring for a client with suspected meningitis. Which priority action should the nurse take following a lumbar puncture (LP) procedure?
- A. Assess the gag reflex
- B. Elevate the head of the bed to 30 degrees
- C. Encourage oral fluid intake
- D. Assess the client for Brudzinski sign
Correct Answer: C
Rationale: Encouraging oral fluid intake (C) post-lumbar puncture helps prevent spinal headache and supports recovery. Assessing gag reflex (A) is unrelated, elevating the head (B) depends on provider orders, and Brudzinski’s sign (D) is assessed before the procedure to diagnose meningitis, not after.
The nurse is educating staff on adult basic life support. It would be appropriate to include which of the following? Select all that apply.
- A. Carotid pulse check should not take more than 20 seconds.
- B. The rate of chest compressions should be 100-120 per minute.
- C. Chest compression depth should be 2 inches on the center breastbone.
- D. Chest tube insertion should be prepared after five minutes of CPR.
- E. Early defibrillation is essential in the survival of ventricular fibrillation.
Correct Answer: B, E
Rationale: Chest compression rate of 100-120/minute (B) and early defibrillation for ventricular fibrillation (E) are correct per AHA guidelines. Pulse check is ≤10 seconds (A), depth is ~2.4 inches (C), and chest tube insertion (D) is not part of BLS.
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 emergency department (ED) nurse is caring for a client who just arrived with a major thermal burn to 22.5% of the total body surface area (TBSA). Place the following actions in the order in which they need to be performed, starting from first to last.
- A. Establish a large bore peripheral vascular access device to unburned skin.
- B. Insert an indwelling urinary catheter to maintain urinary output 0.5 mL/kg/hr.
- C. Administer tetanus prophylaxis as prescribed.
- D. Administer supplemental oxygen if indicated and cover burns with sterile gauze.
- E. Assess the client's airway, breathing, and circulation and obtain vital signs.
- F. Administer prescribed isotonic fluids intravenously to maintain fluid balance.
Correct Answer: E, D, A, F, B, C
Rationale: Initial assessment of airway, breathing, circulation (E) ensures stability, followed by oxygen and burn coverage (D) for hypoxia prevention. IV access (A) and fluids (F) address shock, catheter insertion (B) monitors output, and tetanus prophylaxis (C) is last, as it’s preventive.