Nokea
The nurse is witnessing a client provide informed consent. The client is demonstrating which ethical principle?
- A. Autonomy
- B. Justice
- C. Paternalism
- D. Veracity
Correct Answer: A
Rationale: Informed consent demonstrates autonomy (A), allowing the client to make self-determined decisions, per ethical principles. Justice (B) ensures fairness, paternalism (C) involves decision-making for the client, and veracity (D) is truth-telling, none central to consent.
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The nurse is conducting a staff education program about hand-off reports for clients in an acute care environment. Which of the following should be included during the hand-off report? Select all that apply.
- A. emergency code status
- B. allergies
- C. home medications
- D. admitting diagnosis
- E. review of previous hospitalizations
- F. health insurance status
Correct Answer: A, B, C, D
Rationale: Code status (A), allergies (B), home medications (C), and admitting diagnosis (D) are critical for safe care transitions per ISBAR standards. Previous hospitalizations (E) and insurance status (F) are not essential for immediate handoff.
The nurse is caring for the following assigned clients. The nurse should initially follow-up with the client who
- A. thirty minutes overdue to be ambulated in the hallway.
- B. refusing to eat their meal following an injection of glargine insulin.
- C. scheduled for discharge in three hours and needs transportation.
- D. requesting diphenhydramine after starting an intravenous antibiotic.
Correct Answer: B
Rationale: Refusing to eat after glargine insulin (B) risks hypoglycemia, requiring immediate follow-up to ensure glucose stability. Overdue ambulation (A), discharge planning (C), and diphenhydramine request (D) are less urgent than preventing a metabolic emergency.
The nurse is caring for a group of clients in the labor and delivery department. The nurse should prioritize assessing the client who
- A. is 39 weeks gestation with regular contractions every 3 minutes and reports perineal pressure.
- B. had an epidural placed 3 hours ago and reports a mild headache and has a distended bladder.
- C. delivered a term newborn 4 hours ago and has saturated one peri-pad since delivery and has a temperature of 99.6°F (37.6°C).
- D. is 37 weeks gestation with blood pressure 168/112 mmHg, reports a persistent headache.
Correct Answer: D
Rationale: Severe hypertension (168/112 mmHg) with headache at 37 weeks (D) suggests preeclampsia, a life-threatening emergency requiring immediate assessment to prevent seizures or organ damage. Perineal pressure (A), epidural headache (B), and postpartum findings (C) are less urgent.
The nurse reviews the nursing process with a group of students. Which of the following would demonstrate implementation? Select all that apply.
- A. Performing a sterile dressing change
- B. Interviewing the client about their social determinants
- C. Inputs risk for impaired skin integrity into the care plan
- D. Establishing a peripheral vascular access device
- E. Determining if the prescribed pain medication was effective
Correct Answer: A, D
Rationale: Performing a dressing change (A) and establishing IV access (D) are implementation actions, executing the care plan. Interviewing (B) is assessment, inputting risks (C) is planning, and determining medication effectiveness (E) is evaluation.
The nurse manager plans to reduce supply-related costs within the nursing unit. While evaluating nursing staff, which observation demonstrates an ineffective use of resources? Select all that apply.
- A. Gloves being worn to pass out meal trays
- B. Sterile water used to irrigate nasogastric tubes
- C. Dedicated blood pressure cuffs for clients with contact precautions
- D. Sterile gloves used to provide perineal care during bed baths
- E. New intravenous (IV) tubing with each bag of total parenteral nutrition (TPN)
Correct Answer: A, D
Rationale: Wearing gloves for meal tray distribution (A) and sterile gloves for perineal care (D) are excessive, as non-sterile gloves suffice, wasting resources. Sterile water for NG irrigation (B), dedicated cuffs for precautions (C), and new IV tubing for TPN (E) are appropriate practices.