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Question 2001Question →

At the start of the morning shift, a nurse on a medical unit reviews the client census to determine the sequence of rounds. Arrange the following clients in the order the nurse should assess them, from most urgent to least urgent.

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Answer

The correct assessment sequence is: first, the client with asthma and wheezing; second, the preoperative client with severe abdominal pain; third, the diabetic client needing routine insulin; and finally, the stable client awaiting discharge instructions.
In nursing prioritization, clients experiencing acute changes in airway, breathing, or circulation are always seen first. Therefore, the client with wheezing and tachypnea takes precedence. The next priority is acute pain or potential physiological deterioration, such as the preoperative appendicitis client reporting a sudden increase in pain. Routine, scheduled care for stable clients, like insulin administration, follows acute issues. Finally, stable clients awaiting discharge are the lowest priority for immediate assessment.

Step-by-Step Solution

1
Evaluate the clients for acute airway, breathing, or circulation (ABC) compromise.
The client with asthma, wheezing, and tachypnea is identified as having an acute breathing issue.
Life-threatening physiological needs take the absolute highest priority in clinical decision-making.
2
Assess the remaining clients for acute physiological needs or potential for rapid deterioration.
The preoperative client with a sudden increase in abdominal pain to an 8/10 is identified.
Sudden severe pain in a preoperative appendicitis client could indicate rupture, making this the second highest priority.
3
Review the remaining stable clients for time-sensitive or routine interventions.
The diabetic client needing a morning blood glucose check and insulin is identified.
Routine medications and assessments for stable clients should be completed before non-urgent educational tasks.
4
Identify clients with non-urgent, stable needs.
The client awaiting discharge instructions is identified as the final priority.
Discharge teaching for a medically stable client is the lowest priority and can be safely delayed until all other acute and routine care is provided.

Key Concept

Prioritization using the ABC (Airway, Breathing, Circulation) framework and Maslow's Hierarchy of Needs.
Estimated Time:1m 0s
Question 2002Question →

A client with amyotrophic lateral sclerosis (ALS) is hospitalized and has recently started coughing and clearing their throat frequently during meals. The client's spouse is visibly anxious and asks the nurse if the client is going to choke. Which action by the nurse is the most appropriate to address these concerns?

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Answer: Request a consultation with a speech-language pathologist to evaluate the client's swallowing function.

Answer

The most appropriate action is to request a consultation with a speech-language pathologist to formally evaluate the client's swallowing function.
Clients with progressive neuromuscular diseases, such as ALS, are at an increased risk for developing dysphagia. Coughing during meals is a cardinal sign of potential aspiration. The most appropriate collaborative action is to obtain a consultation with a speech-language pathologist (SLP), as they are the interdisciplinary experts trained to evaluate swallowing safety and recommend appropriate diet modifications.

Step-by-Step Solution

1
Identify the client's primary physiological risk.
The client is demonstrating signs of dysphagia (coughing during meals), which creates a high risk for aspiration.
Recognizing the immediate physical threat dictates the necessary clinical intervention.
2
Select the appropriate interdisciplinary team member for consultation.
A speech-language pathologist (SLP) is identified as the specialist needed for this complication.
SLPs are specially trained to evaluate swallowing function and recommend safe dietary modifications or strategies.
3
Rule out unsafe or nontherapeutic nursing actions.
Delegating assessments, providing false reassurance, and ignoring ABC priorities are rejected.
Safe nursing practice requires maintaining accountability for assessments, using therapeutic communication, and prioritizing physiological needs first.

Key Concept

Interprofessional collaboration for dysphagia management
Estimated Time:45s
Question 2003Question →

A nurse receives the change-of-shift report for four assigned clients on a medical-surgical unit. In what order should the nurse assess these clients? Arrange the clients from highest priority (first to be seen) to lowest priority (last to be seen).

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Answer

The correct order is: the client with difficulty breathing first, followed by the fresh post-operative client, then the client needing scheduled antibiotics, and finally the client requesting comfort measures.
Based on the principles of triage and prioritization in nursing, clients with sudden, unstable airway, breathing, or circulation problems must be seen first. The client with new difficulty breathing (a 'breathing' problem) is the most unstable. Next, a fresh post-operative client returning from the PACU requires an urgent baseline assessment due to the high risk of complications. Third, administering scheduled antibiotics is a priority physiological need but can wait until unstable and high-risk clients are assessed. Finally, attending to the basic comfort needs of a stable client with a chronic condition is the lowest priority.

Step-by-Step Solution

1
Identify the client with a life-threatening, unstable airway or breathing issue.
The client with sudden difficulty breathing and low oxygen saturation is identified as the most unstable.
The ABC (Airway, Breathing, Circulation) framework dictates that respiratory distress is the highest priority.
2
Determine the next most vulnerable or high-risk client among the remaining options.
The client arriving from the PACU requires a prompt baseline assessment.
Fresh post-operative clients are at risk for sudden hemodynamic instability or airway compromise and must be assessed immediately upon arrival to the unit.
3
Evaluate the remaining clients for time-sensitive interventions versus routine comfort needs.
The client requiring scheduled IV antibiotics takes precedence over the client wanting water and a blanket.
Medication administration is a priority physiological intervention compared to basic comfort measures for a stable client.

Key Concept

Establishing Priorities Using the ABC Framework and Patient Stability
Question 2004Question →

A nurse is caring for an older adult client who is scheduled for an elective bronchoscopy. Twenty minutes ago, the client was administered a prescribed dose of intravenous lorazepam to manage severe preoperative anxiety. The pulmonologist just arrived at the bedside and requests that the nurse witness the client signing the informed consent document. Which of the following actions should the nurse take? (Select all that apply)

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Answer: Notify the healthcare provider that the client's current medication status precludes giving legal authorization.; Collaborate with the healthcare provider to contact the client's legally designated surrogate decision-maker.; Ensure the planned procedure is placed on hold until valid authorization is legally secured.

Answer

The correct actions are to notify the provider that the client cannot legally sign, collaborate to contact the designated surrogate decision-maker, and place the procedure on hold until valid consent is secured.
Informed consent requires the client to be voluntarily willing and cognitively competent to understand the risks, benefits, and alternatives of a procedure. Because the client recently received intravenous lorazepam (a sedative), they are considered legally and pharmacologically incompetent to provide valid consent. The nurse acts as a client advocate by stopping the signature process, informing the provider of the medication status, initiating contact with the legal surrogate decision-maker, and ensuring the procedure does not proceed without authorized consent.

Step-by-Step Solution

1
Analyze the client's physiological and legal status.
The client received intravenous lorazepam 20 minutes ago.
Lorazepam is a central nervous system depressant that alters cognition, rendering the client legally incompetent to sign an informed consent document.
2
Determine the appropriate nursing intervention for client advocacy.
The nurse must intervene to prevent the client from signing the document.
The nurse is legally obligated to advocate for the client and ensure that consent is only given voluntarily by a competent individual.
3
Identify the correct legal steps to obtain valid consent.
The medical power of attorney or surrogate must be contacted.
When a client is temporarily incompetent for an elective procedure, informed consent must be deferred to their legally authorized representative.

Key Concept

Clients who have received sedative, analgesic, or mind-altering medications cannot legally provide informed consent. The nurse must act as an advocate by stopping the consent process and directing the provider to the legally authorized surrogate.
Question 2005Question →

A client with a neurocognitive disorder is frequently wandering the hallway during the night shift and entering the rooms of other clients. The unlicensed assistive personnel (UAP) asks the nurse to apply a physical restraint to keep the client safely in bed. Which of the following is the legally appropriate initial action by the registered nurse?

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Answer: Initiate alternative safety interventions, such as a bed exit alarm or moving the client closer to the nursing station.

Answer

Initiate alternative safety interventions, such as a bed exit alarm or moving the client closer to the nursing station.
Clients possess a fundamental legal right to be free from physical and chemical restraints. Before any restraint can be applied, the nurse is legally obligated to exhaust and document all less restrictive alternative measures, such as bed alarms, environmental modifications, or frequent reorientation.

Step-by-Step Solution

1
Identify the core legal issue in the scenario.
The scenario involves a request to apply physical restraints to a wandering client.
Understanding the client's rights regarding restraints is necessary to determine the appropriate nursing action.
2
Apply the legal principle of the least restrictive environment.
The nurse must prioritize interventions that maintain safety while maximizing the client's freedom.
Federal laws and facility policies mandate that physical and chemical restraints are interventions of last resort.
3
Evaluate the options against legal and delegation standards.
Using bed alarms or relocating the client represents required alternative safety measures. Assessing the client cannot be delegated to a UAP, and requesting or applying restraints (physical or chemical) without trying alternatives is legally prohibited.
This process eliminates inappropriate actions and identifies the legally sound initial intervention.

Key Concept

Use of Restraints and Safety Devices (Legal Rights)
Question 2006Question →

A registered nurse (RN) on a general medical unit is coordinating daily care activities with an unlicensed assistive personnel (UAP). Which of the following tasks is most appropriate for the RN to delegate to the UAP?

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Answer: Emptying a urinary catheter drainage bag and recording the total output volume for a stable client.

Answer

Emptying a urinary catheter drainage bag and recording the total output volume for a stable client.
The RN can safely delegate routine, standard procedures that have predictable outcomes to the UAP. Emptying a drainage bag and recording output for a stable client is a basic care task that does not require nursing judgment, clinical assessment, or health teaching.

Step-by-Step Solution

1
Analyze the role and scope of practice of the unlicensed assistive personnel (UAP).
Identify that UAPs can perform routine, standard tasks that do not require clinical judgment, assessment, or teaching.
Understanding scope of practice is essential for safe delegation.
2
Evaluate each provided task against the 'EAT' acronym (Evaluate, Assess, Teach), which are tasks the RN must retain.
Instructing is teaching, auscultating is assessing, and determining pain relief is evaluating.
Applying standard delegation frameworks helps eliminate tasks outside the UAP's scope.
3
Select the task that falls within the UAP's permitted duties.
Emptying a drainage bag and recording the volume is a basic, routine activity of daily living/care.
This task poses minimal risk and requires no independent clinical decision-making.

Key Concept

Delegation to Unlicensed Assistive Personnel (UAP)
Question 2007Question →

An emergency department nurse is preparing a 74-year-old client for an urgent, non-life-threatening surgical procedure. The client speaks only Mandarin. The client's adult son, who is fluent in English, offers to translate the surgeon's explanation of the procedure so the client can sign the informed consent form. The surgeon agrees, explains the procedure to the son, and asks the nurse to witness the client's signature. Which of the following actions should the nurse take? (Select all that apply.)

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Answer: Intervene and notify the surgeon that a certified medical interpreter is required for the informed consent process.; Decline the surgeon's request to witness the client's signature on the informed consent form.; Document the intervention and the requirement for a certified interpreter in the client's medical record.

Answer

The correct actions are to intervene and notify the surgeon that a certified medical interpreter is required, decline to witness the signature, and document the intervention.
For informed consent to be legally valid, the client must fully comprehend the procedure, including its risks, benefits, and alternatives. In non-emergent situations involving a language barrier, standard healthcare policies mandate the use of a trained, certified medical interpreter. Family members should not be utilized because they may lack precise medical vocabulary, omit crucial details, or introduce personal bias. The nurse acts as an advocate by directly intervening, declining to witness a legally flawed consent process, and meticulously documenting the incident to protect the client's rights.

Step-by-Step Solution

1
Analyze the legal and ethical requirements for valid informed consent.
The client must fully understand the risks, benefits, and alternatives of the procedure. Comprehension is severely compromised by a language barrier.
Informed consent is a legal right that requires clear, accurate communication.
2
Evaluate the appropriateness of using a family member as an interpreter.
Family members should not be used as interpreters for informed consent unless it is a life-threatening emergency.
Family members may lack complex medical vocabulary, intentionally or unintentionally omit details, or introduce bias.
3
Determine the nurse's role as a witness to the consent.
The nurse must decline to witness the signature under these circumstances.
The nurse's signature attests that the client is competent, acting voluntarily, and appears to comprehend the information. This cannot be verified without a certified interpreter.
4
Identify appropriate client advocacy and documentation steps.
The nurse must intervene by informing the surgeon of policy requirements and thoroughly document the event.
The nurse functions as a client advocate to ensure legal rights are protected and maintains an objective legal record in the chart.

Key Concept

In non-emergent situations, informed consent for non-English speaking clients strictly requires the use of a certified medical interpreter; family members cannot fulfill this role. The nurse must advocate for this requirement and decline to witness invalid consent.
Question 2008Question →

A client with a history of early-stage dementia is being admitted for an elective cardiac pacemaker insertion. During the admission assessment, the client is fully oriented and accurately explains the procedure, its purpose, and the surgical risks previously outlined by the cardiologist. The client's accompanying adult child reaches for the consent form, asserting that the client's dementia diagnosis automatically revokes their legal right to sign medical documents. Which action should the registered nurse take?

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Answer: Hand the consent form to the client to sign and act as the witness.

Answer

The nurse should allow the client to sign the consent form and act as the witness, because the client demonstrates the capacity to understand the procedure.
Competency for informed consent is based on the client's ability to understand the specific procedure, its risks, benefits, and alternatives at the exact time the consent is signed. A diagnosis of early-stage dementia does not automatically strip a client of their legal right to self-determination. Because this client is oriented and accurately describes the necessary elements of the surgery, they demonstrate the capacity to provide informed consent. The nurse must advocate for the client's autonomy and witness the signature.

Step-by-Step Solution

1
Evaluate the client's current capacity to consent.
The client is oriented and can accurately articulate the procedure, its purpose, and its risks.
Capacity is decision-specific and based on the client's current cognitive state, not simply a medical diagnosis.
2
Identify the legal rights regarding informed consent.
A diagnosis of early-stage dementia does not automatically render the client legally incompetent if they demonstrate understanding of the specific intervention.
Clients retain the right to self-determination unless legally deemed incompetent or currently unable to comprehend the specific medical decision.
3
Determine the appropriate nursing intervention.
The nurse provides the form to the client and acts as a witness.
The nurse acts as an advocate for client autonomy while fulfilling the legal requirement of witnessing a competent client's signature.

Key Concept

Informed Consent and Client Capacity
Estimated Time:1m 0s
Question 2009Question →

While organizing the morning shift workload on a telemetry unit, a registered nurse (RN) is partnered with a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP). Which assignments by the RN represent safe delegation practices? Select all that apply.

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Answer: Assigning the LPN to administer a scheduled oral beta-blocker to a client with chronic atrial fibrillation.; Directing the UAP to measure and record the vital signs of a stable client preparing for discharge.; Assigning the LPN to perform a routine dressing change using sterile technique for a healing abdominal incision.

Answer

The appropriate delegation decisions are assigning the LPN to administer the oral beta-blocker, directing the UAP to measure vital signs for a stable client, and assigning the LPN to perform a routine sterile dressing change.
Safe delegation involves matching the task to the individual's scope of practice and the client's stability. LPNs are licensed to administer oral medications and perform sterile dressing changes on stable, established wounds. UAPs can safely perform routine, non-invasive tasks such as vital sign measurement on stable clients.

Step-by-Step Solution

1
Analyze each client's stability and the complexity of the required task.
Identified that the client with acute dysphagia and the client with sudden shortness of breath are high-risk and unstable.
The 'Right Circumstance' principle of delegation dictates that unstable clients or complex situations require direct RN care.
2
Evaluate the scope of practice for the LPN.
Determined that administering oral medications and performing routine sterile dressing changes are within the LPN's scope, but initiating a discharge teaching plan is not.
LPNs cannot perform initial teaching or nursing assessments, as these require the RN's clinical judgment.
3
Evaluate the scope of practice for the UAP.
Determined that measuring vital signs on a stable client is appropriate, but feeding a client with acute dysphagia or assessing an unstable client's respiratory status is unsafe.
UAPs may only perform routine, standard procedures on stable clients and cannot perform assessments or interventions requiring clinical judgment.

Key Concept

Delegation and Scope of Practice
Question 2010Question →

A nurse is working on an inpatient behavioral health unit caring for a client who was involuntarily committed 48 hours ago following a severe depressive episode. The client is currently pacing the hallway, visibly agitated, and shouting, "I am walking out those doors right now! You have no right to keep me!" Which legally and ethically appropriate actions should the nurse take? Select all that apply.

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Answer: Attempt verbal de-escalation by offering to speak with the client in a quiet, low-stimulation area.; Explain to the client that their involuntary commitment status legally prevents them from leaving.; Offer the client a prescribed as-needed oral antianxiety medication.

Answer

The legally appropriate actions include attempting verbal de-escalation, explaining the legal restrictions of their involuntary commitment, and offering prescribed oral medication.
Clients who are involuntarily committed legally lose the right to leave the facility AMA (Against Medical Advice); therefore, the nurse must truthfully inform them of this restriction. However, these clients retain all other civil rights, including the right to treatment in the least restrictive environment. Attempting verbal de-escalation and offering voluntary oral medications are appropriate, minimally restrictive interventions that respect the client's remaining autonomy and legal rights while ensuring safety.

Step-by-Step Solution

1
Assess the client's legal status and current behavior.
The client is involuntarily committed, meaning they cannot legally leave, but they retain the right to the least restrictive environment despite their agitation.
Understanding the legal parameters of involuntary commitment dictates what the nurse can and cannot enforce.
2
Select interventions based on the principle of least restrictive alternative.
The nurse chooses verbal de-escalation and voluntary oral medications rather than immediate physical restraints.
Legal guidelines require healthcare providers to use the least restrictive means possible to manage agitated behavior, even for clients on psychiatric holds.
3
Determine appropriate nursing scope of practice and communication techniques.
The nurse personally assesses the client rather than delegating, and uses therapeutic honesty regarding the client's legal inability to leave.
Maintaining professional boundaries, accurate legal disclosure, and proper delegation are mandatory legal responsibilities for the RN.

Key Concept

Involuntary Commitment Rights and Least Restrictive Environment
Question 2011Question →

An 82-year-old conscious, intubated client in the intensive care unit is scheduled for a bedside tracheostomy. The client has bilateral soft wrist restraints in place to prevent accidental extubation. Earlier, the healthcare provider explained the procedure, and the client nodded in agreement. Because the client was unable to sign the consent form, the provider obtained telephone consent from the client's legally designated healthcare proxy. As the provider prepares the sterile field, the client's heart rate elevates to 135 bpm, and the client vigorously shakes their head 'no' while attempting to push the provider's hands away with their elbows. Which action should the nurse take first?

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Answer: Halt the procedural setup and advocate for the client by stating they are actively indicating a refusal of the treatment.

Answer

The nurse's priority is to halt the procedural setup and advocate for the client by stating they are actively indicating a refusal of the treatment.
The core principle of informed consent is that a conscious client retains the right to refuse or revoke consent at any time before a procedure begins. Even though the healthcare proxy provided telephone consent because the client physically could not sign, the client's current non-verbal actions clearly indicate a revocation of that consent. The nurse's primary duty as an advocate is to halt the procedure and ensure the client's immediate refusal is respected, preventing potential battery.

Step-by-Step Solution

1
Analyze the client's legal status and capacity to consent or refuse.
The client is conscious, and despite having a proxy consent on file due to a physical inability to sign, the client retains the fundamental right to revoke consent.
A competent, conscious client's immediate wishes always supersede a proxy's previous authorization.
2
Interpret the client's non-verbal communication.
Head shaking and pushing away actively demonstrate a revocation of the prior implied and proxy agreement.
Intubated and physically restrained clients must rely entirely on non-verbal cues to exercise their legal rights.
3
Determine the priority nursing intervention.
The nurse must immediately intervene to stop the provider from continuing.
The nurse acts as the client's advocate to prevent a procedure from occurring against the client's active refusal, which would legally constitute battery.

Key Concept

The right of a conscious client to revoke informed consent at any time prior to a procedure, even non-verbally, supersedes a surrogate's prior authorization.
Question 2012Question →

An experienced registered nurse (RN) is leading a shift on an acute infectious disease unit, collaborating with a licensed practical nurse (LPN/VN) and an unlicensed assistive personnel (UAP). To ensure safe and effective client care, which of the following specific task assignments demonstrates appropriate delegation principles?

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Answer: Designating the LPN/VN to administer scheduled oral antimicrobial therapy to a hemodynamically stable client recovering from localized cellulitis.

Answer

The appropriate delegation is assigning the LPN/VN to administer scheduled oral medications to a stable client with cellulitis.
Administering routine oral medications to a clinically stable client with a predictable condition (such as recovering cellulitis) aligns perfectly with the scope of practice for a Licensed Practical Nurse (LPN/VN). It meets all criteria for safe delegation, freeing the RN to manage more complex and unstable clients on the unit.

Step-by-Step Solution

1
Analyze the acuity and stability of each client presented in the options.
The client with cellulitis is stable. The client experiencing sudden oxygen desaturation is highly unstable and requires immediate advanced assessment.
Delegation decisions must prioritize client safety; unstable clients require the RN's advanced clinical judgment and cannot be delegated to an LPN/VN or UAP.
2
Evaluate the scope of practice for the assigned tasks in the remaining options.
Administering oral medications is within the LPN/VN scope. However, client education on medication regimens is strictly an RN responsibility and outside the UAP scope.
The 'Right Task' and 'Right Person' principles of delegation explicitly prohibit assigning initial health teaching to unlicensed personnel.
3
Assess the infection control instructions provided during the delegation to the UAP.
Advising a UAP to use an alcohol-based hand rub for a client with Clostridioides difficile is a critical clinical error, as soap and water are mandatory for spore-forming bacteria.
The 'Right Direction/Communication' principle requires the RN to provide safe, scientifically accurate instructions regarding transmission-based precautions.

Key Concept

Delegation and Scope of Practice (The Five Rights of Delegation)
Estimated Time:1m 30s
Question 2013Question →

During the initial admission assessment of a client with hepatic cirrhosis, the nurse identifies several clinical findings. Which of the following findings require immediate notification to the healthcare provider? Select all that apply.

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Answer: Emesis of 200 mL of bright red blood; Apical pulse of 118 beats per minute with a blood pressure of 88/54 mm Hg; Sudden onset of spatial disorientation and inability to state the current year

Answer

The findings requiring immediate notification are the emesis of bright red blood, the vital signs indicating potential shock (elevated heart rate with low blood pressure), and the sudden onset of spatial disorientation.
The correct selections represent acute, unexpected, and potentially life-threatening complications of cirrhosis. Hematemesis and hypotensive tachycardia indicate active bleeding and hemodynamic shock (Circulation priority). Acute disorientation indicates worsening hepatic encephalopathy, which is a critical neurological emergency.

Step-by-Step Solution

1
Analyze each clinical finding to determine if it represents an acute, life-threatening complication or an expected, chronic manifestation of hepatic cirrhosis.
Identified acute versus chronic clinical manifestations.
Prioritization requires distinguishing between stable baseline abnormalities and unstable, emergency situations.
2
Evaluate the emesis of bright red blood and the hypotensive, tachycardic vital signs.
Determined these are indicators of active hemorrhage and hemodynamic instability.
Airway and Circulation (ABC) compromises are the highest priority and require immediate medical intervention.
3
Evaluate the sudden spatial disorientation.
Determined this is an acute neurological decline indicating hepatic encephalopathy.
Acute changes in mental status are medical emergencies that can rapidly progress to airway compromise or coma.
4
Evaluate the scleral icterus (yellowing) and spider angiomas.
Determined these are expected, chronic disease manifestations.
Expected findings, even when significantly abnormal from a healthy baseline, do not require immediate emergency notification.

Key Concept

In clinical prioritization, acute, unexpected, and life-threatening complications (such as active hemorrhage, shock, and acute neurological decline) must be addressed before chronic, expected disease manifestations.
Estimated Time:1m 30s
Question 2014Question →

A nurse is preparing to contact the healthcare provider to report a sudden change in a client's condition. The client was admitted with a right femur fracture and has unexpectedly developed severe shortness of breath. Arrange the nurse's statements in the correct chronological order according to the SBAR (Situation, Background, Assessment, Recommendation) communication tool.

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Answer

The correct SBAR sequence is: 1) Situation (identifying caller, patient, and immediate issue), 2) Background (admission reason and relevant history), 3) Assessment (current vitals and clinical findings), and 4) Recommendation (requesting orders or provider evaluation).
The SBAR tool provides a standardized framework for effective interprofessional communication. 'Situation' immediately alerts the provider to the primary concern. 'Background' gives the necessary clinical context. 'Assessment' provides the current data supporting the concern. 'Recommendation' clearly states what intervention or action is needed from the provider to ensure client safety.

Step-by-Step Solution

1
Identify the 'Situation' statement.
Select the statement introducing the nurse, the client, and the primary problem (sudden shortness of breath).
SBAR begins by immediately alerting the provider to the core reason for the communication.
2
Identify the 'Background' statement.
Select the statement discussing the femur fracture admission and the history of asthma.
The provider needs historical context to understand the current situation.
3
Identify the 'Assessment' statement.
Select the statement reporting the current oxygen saturation of 88%, respiratory rate of 28, and anxiety.
Current clinical data supports the severity of the situation and helps the provider formulate a plan.
4
Identify the 'Recommendation' statement.
Select the statement asking for supplemental oxygen orders and an immediate evaluation.
The communication must conclude with a clear request for action to address the client's needs.

Key Concept

SBAR Communication Framework in Interdisciplinary Collaboration
Question 2015Question →

A registered nurse (RN) team leader is coordinating care on a busy medical-surgical unit with a staffing mix that includes a newly licensed RN, a licensed practical/vocational nurse (LPN/VN), and an unlicensed assistive personnel (UAP). Shortly after the change-of-shift report, the team leader receives several urgent notifications from the care team. Based on the principles of prioritization and delegation supervision, arrange the following team member reports in the order the team leader must assess and address them, from highest priority (first) to lowest priority (last).

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Answer

The RN should first address the ACDF client (airway risk), followed by the SCI client (autonomic dysreflexia), the heparin client (internal bleeding), the TURP client (catheter obstruction), and finally the UAP's question regarding SCDs (routine supervision).
In the context of delegation and team supervision, the RN remains accountable for analyzing reports from team members and prioritizing interventions based on the severity of the client's condition. Using the ABC (Airway, Breathing, Circulation) framework: The post-ACDF client with neck tightness indicates a potential hematoma causing airway obstruction (Priority 1). The SCI client with autonomic dysreflexia represents a life-threatening hypertensive crisis (Priority 2). The client on heparin with hematuria and back pain indicates active internal hemorrhage (Priority 3). The TURP client with a blocked catheter requires urgent intervention to prevent organ damage, but is clinically more stable than the first three (Priority 4). Finally, answering a UAP's question about a routine, non-urgent task is a necessary supervisory duty but represents the lowest priority (Priority 5).

Step-by-Step Solution

1
Evaluate reports using the ABC (Airway, Breathing, Circulation) framework.
The ACDF client has a potential airway obstruction due to a possible hematoma.
Airway emergencies represent the most immediate threat to life and are always the absolute highest priority.
2
Evaluate remaining reports for imminent life-threatening conditions.
The SCI client has a hypertensive emergency indicative of autonomic dysreflexia.
Neurological emergencies with severe vital sign instability take precedence over localized or slower-developing circulatory issues.
3
Assess remaining clients for severe circulatory compromise and acute organ risk.
The heparin client exhibits signs of systemic internal hemorrhage, prioritizing over the TURP client's localized obstruction.
Systemic hemorrhage is a more immediate threat to hemodynamic stability than a blocked bladder catheter, despite the latter causing severe pain.
4
Differentiate between urgent clinical interventions and administrative or supervisory tasks.
The UAP's clarification request regarding SCDs is identified as a non-urgent supervisory task.
Routine supervision and education of assistive personnel regarding stable tasks always follows critical clinical interventions.

Key Concept

Prioritization of Care and Delegation Supervision
Question 2016Question →

A young adult client with a history of schizophrenia is admitted to a medical-surgical unit with acute appendicitis. The client is oriented to person, place, and time, but is currently experiencing auditory hallucinations. The surgeon explains the proposed appendectomy, and the client agrees to the surgery, stating, "The voices told me this operation will finally remove the alien tracking device from my stomach." The surgeon leaves the consent form at the bedside for the nurse to witness. Which action should the nurse take?

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Answer: Withhold witnessing the signature and notify the surgeon that the client's capacity to consent is impaired by delusional reasoning.

Answer

The correct action is to withhold witnessing the signature and notify the surgeon that the client's capacity to consent is impaired by delusional reasoning.
The correct answer involves halting the consent process and notifying the provider. For informed consent to be legally valid, the client must possess the cognitive capacity to understand the nature of the procedure, its risks, and its benefits. Although the client is willing to undergo the surgery, their reasoning is based entirely on a psychotic delusion. This indicates a profound inability to appreciate the medical reality of the situation. As a patient advocate and witness to the consent process, the registered nurse has a legal and ethical duty to ensure the client is truly competent. Therefore, the nurse must withhold their signature and inform the surgeon, who must then formally assess the client's capacity and potentially seek surrogate consent.

Step-by-Step Solution

1
Evaluate the client's understanding of the proposed surgical procedure.
The client voluntarily agrees to the surgery, but does so to remove an 'alien tracking device', which is a delusional belief.
The nurse's role in informed consent includes verifying that the client comprehends the true nature of the intervention.
2
Determine if the client meets the legal criteria for informed consent capacity.
The client lacks the capacity to appreciate the actual medical reality, risks, and benefits of the appendectomy.
Competency and capacity require rational decision-making abilities, which are currently compromised by active psychosis.
3
Identify the appropriate nursing intervention based on the scope of practice.
The nurse must stop the consent process and communicate the findings to the healthcare provider.
The registered nurse cannot witness an invalid consent and must advocate for the client by ensuring the provider is aware of the impaired capacity so appropriate legal and ethical steps can be taken.

Key Concept

Informed Consent and Capacity Assessment in Psychiatric Clients
Question 2017Question →

A 45-year-old client admitted to the medical-surgical unit is receiving intravenous (IV) antibiotics for severe community-acquired pneumonia. The client states, 'I am feeling much better and I need to go home right now to take care of my dog.' The client is alert, oriented, and demonstrates decision-making capacity. Arrange the following nursing actions in the correct chronological order.

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Answer

The correct sequence is to first assess and address the client's underlying concern, followed by explaining the medical risks of leaving. Next, the nurse should notify the healthcare provider, request the client's signature on the AMA form, and finally remove the IV catheter and document the entire event.
The proper response to a client wanting to leave Against Medical Advice (AMA) follows the nursing process and legal principles of client autonomy. First, the nurse must assess the underlying reason to see if it can be resolved. If the client insists on leaving, the nurse must immediately ensure they are informed of the health risks. Following this, the healthcare provider is notified so they can intervene or adjust the care plan. The nurse then asks the client to sign the AMA form for legal documentation. Finally, the nurse removes invasive devices, provides any necessary instructions, and documents the entire encounter objectively.

Step-by-Step Solution

1
Assess and address the root cause.
Explores if the client's concern can be mitigated without them leaving the hospital.
Resolving the modifiable issue (care for the dog) is the most effective way to keep the client safe and ensure treatment completion.
2
Educate the client on potential medical risks.
Fulfills the nurse's ethical and legal obligation for informed refusal.
The client must understand the severe consequences of stopping treatment prematurely to make a legally valid decision.
3
Communicate with the healthcare provider.
Informs the medical team of the client's decision.
The provider must be notified to offer further medical intervention or arrange for alternative care, such as oral antibiotics.
4
Obtain the AMA signature.
Secures legal documentation of the client's informed refusal.
Signing the AMA form legally protects the hospital and healthcare providers from malpractice claims if the client deteriorates after leaving.
5
Perform safe discharge procedures and document.
Ensures the client leaves safely and the event is permanently recorded.
The nurse must safely discontinue therapies (like IVs) and thoroughly document the facts, the education provided, and the client's capacity.

Key Concept

Nursing Management of Against Medical Advice (AMA) Refusal of Care
Question 2018Question →

During morning rounds on a medical-surgical floor, the nurse must determine the sequence of client assessments. Which client requires the nurse's immediate attention?

Show answer & explanation

Answer: A client receiving a new intravenous antibiotic infusion who reports a scratchy throat and tightness in the chest.

Answer

The client receiving a new intravenous antibiotic infusion who reports a scratchy throat and tightness in the chest.
The correct answer identifies a client experiencing early symptoms of anaphylaxis (scratchy throat, chest tightness) in response to a new medication. According to the ABC (Airway, Breathing, Circulation) framework, a potential airway obstruction is a life-threatening emergency that must be addressed before any other client needs.

Step-by-Step Solution

1
Analyze each client's condition using the Airway, Breathing, Circulation (ABC) prioritization framework.
The client receiving the antibiotic is showing signs of airway compromise. The other clients have routine, expected, or comfort-related needs.
The ABC framework is the standard method for identifying life-threatening emergencies that require immediate intervention.
2
Compare the urgency of the identified needs.
Airway compromise (anaphylaxis) is a critical, life-threatening situation that takes precedence over pain, routine medication administration, and stable blood glucose levels.
Immediate action is required to maintain a patent airway and prevent respiratory failure.

Key Concept

Prioritizing client care based on the Airway, Breathing, and Circulation (ABC) framework.
Question 2019Question →

A registered nurse is assigned to a young adult client who is scheduled to undergo an elective cholecystectomy later today. The surgeon has just left the room after discussing the operation with the client. Which action is the primary responsibility of the nurse during the informed consent process?

Show answer & explanation

Answer: Witnessing the client voluntarily sign the informed consent document.

Answer

Witnessing the client voluntarily sign the informed consent document.
The correct answer accurately reflects the nurse's legal scope of practice. The nurse's primary responsibility during informed consent is to act as an advocate and witness, verifying that the client gave consent voluntarily, is competent to do so, and understands what the healthcare provider discussed.

Step-by-Step Solution

1
Identify the core concept being tested in the scenario.
The question asks for the nurse's primary role in the informed consent process after the provider has explained the procedure.
Understanding the legal boundaries of nursing practice is essential for safe client care.
2
Differentiate between the healthcare provider's role and the nurse's role in informed consent.
The provider explains the procedure, risks, benefits, and alternatives. The nurse acts as a witness to the signature and verifies voluntariness.
Maintaining clear role boundaries prevents legal liabilities and ensures the client receives proper medical disclosures from the qualified practitioner.
3
Evaluate the options against the nurse's legal scope of practice.
Only witnessing the signature falls within the nurse's legal role for informed consent.
Explaining risks is the provider's job, delegating this task to a UAP is inappropriate, and giving false reassurance is non-therapeutic.

Key Concept

The nurse's role in informed consent is to witness the signature, confirm voluntariness, and verify competency, rather than explaining the medical details of the procedure.
Question 2020Question →

A nurse is reviewing facility policies regarding client confidentiality and information security. Which of the following actions by the nurse demonstrate adherence to these guidelines? (Select all that apply.)

Select all that apply

Show answer & explanation

Answer: Logging off the electronic health record immediately after finishing documentation.; Placing printed shift report sheets in a secure shredding receptacle at the end of the shift.; Minimizing the computer screen displaying client data when an unauthorized individual approaches the workstation.

Answer

The correct actions are logging off the electronic health record immediately after use, placing printed shift reports in a secure shredding receptacle, and minimizing the computer screen when an unauthorized person approaches.
Protecting client confidentiality requires strict adherence to physical and electronic safeguards. These include securing devices by logging off or minimizing screens when not in active use, and properly destroying physical documents containing protected health information. These routine actions are fundamental in preventing unauthorized access to sensitive data.

Step-by-Step Solution

1
Identify actions that appropriately protect electronic and physical health information.
Logging off, minimizing screens, and shredding documents are recognized as proper security measures.
These actions actively prevent unauthorized visual and physical access to protected health information.
2
Evaluate the remaining actions for legal or ethical violations.
Sharing passwords, keeping abuse a secret, and sharing data with unapproved family members are identified as violations.
Credentials must never be shared, mandatory reporting overrides confidentiality, and explicit consent is required before disclosing information to family members.

Key Concept

Confidentiality and Information Security
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