Nokea
The nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse comprises a tort?
- A. Administering the medication to a client behind a closed curtain.
- B. Informing a client that the medication being administered is a vitamin.
- C. Placing a client in restraints without having a healthcare provider’s order.
- D. Enlisting security personnel to assist with restraining the client.
Correct Answer: B
Rationale: Deception violates informed consent.
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A 16-year-old emancipated client is being seen in the emergency department following a minor automobile accident. The client’s parents arrive and are asking about the client’s laboratory results. Which response is best for the nurse to provide?
- A. The healthcare provider will share this information with you.'
- B. I’m sorry, but your child’s medical information is none of your business.'
- C. I can give you those results as soon as I get them back from the laboratory.'
- D. I can only give medical information to your child because they are legally an adult.'
Correct Answer: D
Rationale: Emancipated minors have autonomy.
The nurse is caring for a client with type 2 diabetes mellitus who had surgery for a large bowel resection with a colostomy placement. The client has now developed hyperglycemia which requires self-injections of insulin after discharge. When designing the postoperative plan of care, which outcome statement should the nurse use?
- A. The client will demonstrate the ability to change the ostomy bag in two days.
- B. The client attempts to self-administer insulin but is unable to perform the injection.
- C. The client’s breath sounds will be auscultated by the nurse every 4 hours.
- D. The client will adhere to the medication regimen after discharge.
Correct Answer: D
Rationale: Medication adherence manages hyperglycemia.
Which assessment should the nurse document when charting by exception?
- A. Active bowel sounds in the lower right quadrant.
- B. Contraction of the left pupil when light shines in the right eye.
- C. Basilar lung sounds that are diminished in the left lung.
- D. Capillary refill of 2 seconds in the lower right foot.
Correct Answer: C
Rationale: Abnormal findings are documented.
The nurse is demonstrating three-point gait crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior indicates that the client understands proper crutch walking?
- A. Inspects crutches to ensure rubber tips are intact.
- B. Practices bicep and triceps isometric exercises.
- C. Bears body weight on the palms of hands during the crutch gait.
- D. Progresses to foot touchdown and weight bearing of the affected leg.
Correct Answer: C
Rationale: Inspecting tips ensures safety.
To assess the quality of the client’s abdominal pain, which approach should the nurse use?
- A. Provide a numeric pain scale.
- B. Ask the client to describe the pain.
- C. Observe body language and movement.
- D. Identify effective pain relief measures.
Correct Answer: B
Rationale: Descriptive assessment captures pain quality.