Nokea
The nurse is observing a client using a walker. Which observation by the nurse should determine that the client is using the walker correctly?
- A. Puts weight on the hand pieces, slides the walker forward, and then walks into it
- B. Puts weight on the hand pieces, moves the walker forward, and then walks into it
- C. Puts all four points of the walker flat on the floor, puts weight on the hand pieces, and then walks into it
- D. Walks into the walker, puts weight on the hand pieces, and then puts all four points of the walker flat on the floor
Correct Answer: C
Rationale: To use a walker correctly, the client should place all four points of the walker flat on the floor to ensure stability, then put weight on the hand pieces to support their body, and finally walk into the walker. This sequence ensures the walker remains stable and provides maximum support. Option 1 is incorrect because sliding the walker can cause instability. Option 2 is incorrect because moving the walker forward without ensuring all points are flat may lead to tipping. Option 4 is incorrect because walking into the walker before placing it flat reverses the proper sequence and compromises safety.
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A client asks the home care nurse to witness the client's signature on a living will with the client's attorney in attendance. Which action is most appropriate for the nurse to implement?
- A. Decline to witness the signature on the living will.
- B. Sign the living will as a witness to the signature only.
- C. Notify the supervisor that a living will is being witnessed.
- D. Sign the living will with identifying credentials and employment agency.
Correct Answer: A
Rationale: Living wills are written documents and need to be signed by the client. The client's signature must be either witnessed by nonagency individuals or notarized; thus, the nurse should decline to sign the will to avoid a conflict of interest. There is no need to contact the supervisor or sign the living will with or without credentials because the nurse cannot sign this document as a witness. Therefore, options 2, 3, and 4 are incorrect.
The nurse manager is developing an educational session for nursing staff on the components of informed consent and the information to be shared with a client to obtain informed consent. Which information should the nurse manager include in the session? Select all that apply.
- A. The client needs to be informed of the prognosis if the test, procedure, or treatment is refused.
- B. The client cannot refuse a test, procedure, or treatment once the test, procedure, or treatment is started.
- C. The name(s) of the persons performing the test or procedure or providing treatment should be documented on the informed consent form.
- D. A description of the complications and risks of the test, procedure, or treatment, as well as anticipated pain or discomfort, needs to be explained to the client.
- E. The nurse is responsible for obtaining the client's signature on an informed consent form even if the client has questions about the test, procedure, or treatment to be performed.
Correct Answer: A,C,D
Rationale: Informed consent is a person's agreement to allow something to happen based on full disclosure of risks, benefits, alternatives, and consequences of refusal. The primary health care provider (HCP) is responsible for conveying information and obtaining the informed consent. The nurse may be the person who actually ensures that the client signs the informed consent form; however, the nurse does this only after the HCP has instructed the client, and it has been determined that the client has understood the information. The following factors are required for informed consent: a brief, complete explanation of the test, procedure, or treatment; names and qualifications of persons performing and assisting in the test, procedure, or treatment; a description of the complications and risks, as well as anticipated pain or discomfort; an explanation of alternative therapies to the proposed test, procedure, or treatment, as well as the risks of doing nothing; and the client's right to refuse the test, procedure, or treatment even after it has been started.
The nurse is administering a dose of prescribed intravenous hydralazine to a client. To provide a safe environment, the nurse should ensure that which safety measure is in place before injecting the medication?
- A. Central line
- B. Thermometer
- C. Foley catheter
- D. Blood pressure cuff
Correct Answer: D
Rationale: Hydralazine is an antihypertensive medication used in the management of moderate to severe hypertension. The blood pressure and pulse should be monitored frequently after administration, so a blood pressure cuff is the item to have in place. Although intravenous access is needed, a central line is unnecessary. The other options are also unnecessary and are unrelated to the administration of this medication.
A pregnant client tests positive for the hepatitis B virus. The client asks the nurse if she will be able to breast-feed the baby as planned after delivery. Which therapeutic response should the nurse communicate to the client?
- A. You will not be able to breast-feed the baby until 6 months after delivery.
- B. Breast-feeding is not advised, and you should seriously consider bottlefeeding the baby.
- C. Breast-feeding is not a problem, and you will be able to breast-feed immediately after delivery.
- D. Breast-feeding is allowed if the baby receives prophylaxis treatment at birth and scheduled immunizations.
Correct Answer: D
Rationale: The pregnant client who tests positive for hepatitis B virus should be reassured that breast-feeding is not contraindicated if the infant receives prophylaxis at birth and remains on the schedule for immunizations. Therefore, options 1, 2, and 3 are incorrect.
In which situation is the nurse manager utilizing an autocratic leadership style?
- A. The nurse manager provides the solution for a unit problem.
- B. The nurse manager allows the staff to solve their own unit problem.
- C. The nurse manager proposes several alternatives and has the unit staff vote on the best proposal.
- D. The nurse manager arranges for a staff meeting where all unit employees can share proposals to solve a problem.
Correct Answer: A
Rationale: The autocratic style of leadership is task oriented and directive. The leader uses his or her power and position in an authoritarian manner to set and implement organizational goals or solutions. Decisions are made without input from the staff. The situational leadership style uses a style depending on the situation and events. Democratic styles best empower staff toward excellence because this style of leadership allows nurses to provide input regarding the decision-making process and an opportunity to grow professionally. Participatory leadership encourages input from the staff.