Nokea
While performing a physical assessment on a 6-month-old infant, the nurse observes head lag. Which of the following nursing actions should the nurse perform first?
- A. Ask the parents to allow the infant to lay on her stomach to promote muscle development
- B. Notify the physician because a developmental or neurological evaluation is indicated
- C. Document the findings as normal in the nurse's notes
- D. Explain to the parents that their child is likely to be mentally retarded
Correct Answer: B
Rationale: Persistent head lag at 6 months suggests developmental or neurological issues, warranting immediate physician referral for evaluation.
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The ICU nurse caring for a client who has just been declared brain dead can expect to find evidence of the client's wishes regarding organ donation:
- A. on the driver's license of the client.
- B. in the client's safety deposit box.
- C. in the client's last will and testament.
- D. on the client's insurance card.
Correct Answer: A
Rationale: In most states, indication of organ donor status is found on the driver's license. Evidence in a last will and testament or in a safety deposit box is not readily accessible for decision-making if the need arises. Insurance cards do not contain such information.
The LPN needs to delegate a task to the nurse aide who is new to the unit. Which of these is the best option for the nurse to choose in proceeding?
- A. Delegate the task to the nurse aide, confirm understanding, and follow up to ensure the task was safely/correctly done.
- B. Delegate the task to the nurse aide, watch them perform the task without them seeing you, and follow up to ensure the task was done safely/accurately.
- C. Delegate the task to the nurse aide, supervise if needed and check in after the task to see if help is needed.
- D. Delegate the task to the nurse aide, ensure understanding of the task, and supervise task being performed.
Correct Answer: A
Rationale: Delegation is transferring responsibility for a task but sharing its accountability. It is the delegator's responsibility to make sure the delegatee understands the task prior and to follow up after to make sure it was done correctly and safely.
The nurse and a colleague are on the elevator after their shift, and they hear a group of health caregivers discussing a recent client scenario. Which client right might be breached?
- A. right to refuse treatment
- B. right to continuity of care
- C. right to confidentiality
- D. right to reasonable responses to requests
Correct Answer: C
Rationale: The right to confidentiality of client information might be breached when client care situations are discussed in public areas or without regard to maintaining the information as private and confidential. The other rights listed have not been breached in this instance.
Which of the following activities is not part of client advocacy?
- A. involving the client in treatment and decision making
- B. standing up for what is right for the client
- C. sharing your personal opinions to help provide additional information
- D. encouraging the client to advocate for themselves
Correct Answer: C
Rationale: To be a good client advocate, the nurse should not tell the client what they personally think about a decision the client is making.
The team is in the client's room to insert a chest tube, and the nurse suspects that the attending physician who is going to perform the procedure is intoxicated. Which of the following actions is most appropriate?
- A. Report the concern to the charge nurse.
- B. Leave the room immediately so as not to be held liable for any complications.
- C. During the procedure, begin writing an incident report.
- D. Observe the physician while performing the procedure with extra attention to make sure no mistakes occur.
Correct Answer: A
Rationale: When there is a concern about a potentially unsafe health care provider, the nurse should intervene immediately and not allow the physician to continue with the procedure until the concern is investigated; the concern should be reported to the next person in the chain of command. An incident report can be written following reporting and an investigation.