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The nurse is discussing information about advanced directives with a client who expresses concerns, asking, 'What if I change my mind about what I want?' What approach would you use to respond to the client's care?
- A. Explain that the client would have to file a new witnessed document in order to make any changes.
- B. Discuss the need to be very sure about his preferences, as the living will is a binding legal document.
- C. Assure the client that he can change or revoke his advanced directives at any time.
- D. Advise the client that changes could not be made during this hospital stay.
Correct Answer: C
Rationale: Clients can change or revoke advance directives at any time (C), ensuring autonomy. New documents (A) may be needed but not restrictive, living wills are not unchangeable (B), and hospital stay (D) does not limit changes.
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The nurse is planning care for a client being admitted with cardiac dysrhythmias. When planning care for this client, the nurse should prioritize
- A. auscultating heart tones.
- B. establishing continuous electrocardiogram (ECG) monitoring.
- C. obtaining vital signs.
- D. establishing a secondary peripheral vascular access device.
Correct Answer: B
Rationale: Continuous ECG monitoring (B) is the priority for cardiac dysrhythmias to detect and manage life-threatening arrhythmias in real-time. Auscultating heart tones (A), vital signs (C), and IV access (D) are important but secondary to monitoring.
The nurse is reviewing leadership and management concepts with a student nurse. The student nurse demonstrates understanding if they made which of the following statements? Select all that apply.
- A. Battery is an intentional touching of another's body without the other's consent.'
- B. Assault is when the nurse makes a verbal or physical threat.'
- C. Unintentional torts include negligence and malpractice.'
- D. Defamation is presenting false credentials for employment.'
- E. Occurrence reports reduce the liability for a negligent tort.'
Correct Answer: A, B, C
Rationale: Battery (A) is non-consensual touching, assault (B) is a threat, and negligence/malpractice (C) are unintentional torts, all correct. Defamation (D) involves false statements harming reputation, not credentials, and occurrence reports (E) document but don’t reduce liability.
The registered nurse (RN) delegates client assignments to a licensed practical/vocational (LPN/VN) and unlicensed assistive personnel (UAP). Which client assignment should be delegated to a UAP? A client
- A. newly diagnosed with hypothyroidism and requires teaching.
- B. admitted with atrial fibrillation that requires vital signs every three hours
- C. immediately postoperative following total hip arthroplasty that is reporting pain.
- D. ready for discharge and requires reinforcement of discharge instruction.
Correct Answer: B
Rationale: Taking vital signs every three hours for a client with atrial fibrillation (B) is a routine task suitable for a UAP. Teaching (A), managing postoperative pain (C), and reinforcing discharge instructions (D) require nursing judgment, reserved for RNs or LPNs.
The emergency department (ED) nurse is assigned clients with assigned clients. Place the actions in the order of priority, starting with the highest priority.
- A. Dress a wound for a client discharged with multiple lacerations to the right arm.
- B. Insert a peripheral vascular access device for a client with mild dehydration and infuse prescribed fluids.
- C. Assess a client’s blood pressure who is receiving an infusion of dopamine.
- D. Witness informed consent for a client scheduled for surgery in six hours.
- E. Administer prescribed magnesium sulfate infusion for a client with status asthmaticus.
Correct Answer: C, E, B, D, A
Rationale: Assessing BP on dopamine (C) ensures hemodynamic stability, followed by magnesium for status asthmaticus (E) to control life-threatening bronchospasm. IV access for dehydration (B), informed consent (D), and wound dressing (A) are less urgent, as they address stable or non-emergent needs.
The nurse is caring for a 13-year-old in the pediatric unit with a left-side below-the-knee cast. The client reports pain and numbness in the foot. The nurse notes that the toes of the left foot are cold. Which of the following actions should the nurse take first?
- A. Remove the cast.
- B. Have the child ambulate.
- C. Notify the physician.
- D. Elevate the leg on two pillows.
Correct Answer: C
Rationale: Pain, numbness, and cold toes in a casted limb (C) suggest compartment syndrome, a medical emergency requiring immediate physician notification to prevent tissue damage. Removing the cast (A), ambulating (B), or elevating (D) without orders could worsen the condition.