Nokea
The nurse is in an elevator and overhears two staff members discussing a client's condition. Which ethical principle does the nurse recognize may be potentially violated by this conversation?
- A. Beneficence
- B. Confidentiality
- C. Autonomy
- D. Veracity
Correct Answer: B
Rationale: Discussing a client’s condition in public violates confidentiality (B), as it breaches HIPAA and the client’s right to privacy. Beneficence (A), autonomy (C), and veracity (D) are unrelated to unauthorized disclosure of health information.
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The infection control nurse delegates tasks to staff to reduce hospital-acquired infections. Which task would be appropriate to delegate to the unlicensed assistive personnel (UAP)?
- A. Educate staff members on actions to reduce central line-associated bloodstream infections
- B. Demonstrating correct handwashing techniques to visitors
- C. Restocking personal protective equipment (PPE)
- D. Screening visitors for respiratory infections
Correct Answer: C
Rationale: Restocking PPE (C) is a non-clinical task within the UAP’s scope. Educating staff (A), demonstrating handwashing (B), and screening visitors (D) require clinical judgment or training, inappropriate for UAPs.
The emergency department (ED) is caring for a client with a pulse (P) of 42, blood pressure (BP) of 90/60 mm Hg, and reports dizziness. Which of the following actions is the priority?
- A. Obtain an order for a chest radiograph (x-ray)
- B. Review the client's current medications
- C. Perform a focused neurological assessment
- D. Obtain a 12-lead electrocardiogram (ECG)
Correct Answer: D
Rationale: A pulse of 42 with hypotension and dizziness (D) suggests symptomatic bradycardia, requiring an immediate ECG to identify arrhythmias, per ACLS guidelines. Chest x-ray (A), medication review (B), and neurological assessment (C) are secondary to cardiac evaluation.
The registered nurse (RN) supervises a licensed practical/vocational nurse (LPN). Which statement by the LPN/VN requires follow-up by the RN?
- A. I bathed the client already this morning'
- B. I passed out letters and packages to the clients this morning.'
- C. The client refused his prescribed valproic acid, so I snuck it into his food.'
- D. I will be joining the clients with their games today in the day room.'
Correct Answer: C
Rationale: Hiding medication in food (C) is unethical, unsafe, and violates client autonomy, requiring immediate RN follow-up. Bathing (A), distributing mail (B), and joining games (D) are within the LPN’s scope and do not require intervention.
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).
The nurse is performing an assessment on an older adult. Which finding requires immediate followup?
- A. dysphagia
- B. stress incontinence
- C. dry, flaky skin
- D. hearing loss
Correct Answer: A
Rationale: Dysphagia (A) in older adults risks aspiration and malnutrition, requiring immediate follow-up to ensure safety. Stress incontinence (B), dry skin (C), and hearing loss (D) are common but less urgent concerns.