Examkin

All practice questions

3881 questions

All types3,881Multiple choice1,926Multiple select908Numeric119Matching66Ordering862
Question 2341Question →

An emergency department nurse is evaluating a client who arrived 2 hours ago after sustaining blunt anterior chest trauma in a motor vehicle collision. Which of the following assessment findings are critical cues that require immediate notification of the healthcare provider? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Tracheal deviation away from the midline; A narrowing pulse pressure from 42 mm Hg to 20 mm Hg; Paradoxical inward movement of a chest wall segment during inspiration

Answer

The critical cues requiring immediate notification are tracheal deviation, narrowing pulse pressure, and paradoxical chest wall movement.
The correct findings all represent immediate threats to the client's airway, breathing, or circulation (ABCs). Tracheal deviation is a hallmark sign of a tension pneumothorax. A narrowing pulse pressure is an early indicator of cardiac tamponade or shock. Paradoxical chest movement indicates a flail chest, which severely compromises ventilation. All three require emergent life-saving interventions.

Step-by-Step Solution

1
Analyze the client's clinical presentation and mechanism of injury.
The client has blunt anterior chest trauma, putting them at high risk for intrathoracic injuries affecting airway, breathing, and circulation (ABCs).
Understanding the mechanism of injury helps anticipate life-threatening complications.
2
Evaluate each assessment finding against the ABC prioritization framework.
Tracheal deviation (Airway/Breathing), paradoxical chest movement (Breathing), and narrowing pulse pressure (Circulation) all represent acute, systemic life threats.
The ABCs framework dictates that physiological threats to survival must be addressed before expected or localized findings.
3
Differentiate expected from unexpected or critical findings.
Severe chest pain and sternal ecchymosis are expected sequelae of blunt chest trauma and do not pose immediate threats to life.
Prioritization requires the nurse to separate normal disease progression or expected trauma outcomes from acute clinical deterioration.

Key Concept

Prioritization of critical cues using the Airway, Breathing, Circulation (ABC) framework and distinguishing life-threatening complications of chest trauma from expected findings.
Question 2342Question →

A nurse is caring for a client who is confused, restless, and continuously attempting to get out of bed without assistance. Which intervention should the nurse implement first to promote a safe environment?

Show answer & explanation

Answer: Activate a bed exit alarm and maintain the bed in the lowest possible position.

Answer

Activate a bed exit alarm and maintain the bed in the lowest possible position.
The safest and most appropriate initial intervention is to use a bed exit alarm and keep the bed in the lowest position. This approach adheres to the nursing principle of utilizing the least restrictive means necessary to ensure client safety while immediately addressing the fall risk.

Step-by-Step Solution

1
Analyze the client's condition and identify the immediate safety risk.
The client is confused, restless, and attempting to get out of bed, presenting a high and immediate risk for a fall.
Identifying the primary risk is the first step in determining the appropriate nursing intervention.
2
Evaluate potential interventions based on the principle of the least restrictive environment.
A bed alarm and a lowered bed are non-restrictive measures that address the safety risk without limiting the client's freedom unnecessarily.
Nursing standards require exhausting all less restrictive alternatives before considering any form of physical restraint.
3
Select the safest, most immediate action.
Activating the bed alarm and lowering the bed is determined to be the priority action.
This intervention directly mitigates the fall risk while adhering to core safety and legal protocols.

Key Concept

Prioritizing least restrictive safety measures and immediate injury prevention for confused clients.
Question 2343Question →

A nurse is developing an interdisciplinary care plan for an 8282-year-old client recovering in a rehabilitation unit following a complex cerebrovascular accident (CVA). The client has regained independent ambulation but exhibits new-onset dysphagia and profound fine motor deficits, rendering them unable to grasp standard eating utensils. The client's spouse is visibly distressed regarding the client's poor nutritional intake. Which collaborative action represents the most appropriate interdisciplinary management?

Show answer & explanation

Answer: Consulting an occupational therapist to address the fine motor deficits and a speech-language pathologist to perform a comprehensive swallowing evaluation.

Answer

The most appropriate action is consulting an occupational therapist to address the fine motor deficits and a speech-language pathologist to perform a comprehensive swallowing evaluation.
The correct action accurately matches the client's specific clinical needs with the appropriate allied health scopes of practice. An occupational therapist (OT) specializes in evaluating and treating fine motor deficits and promoting independence in activities of daily living, such as providing adaptive utensils for eating. A speech-language pathologist (SLP) is the highly specialized interdisciplinary team member trained to conduct a comprehensive swallowing evaluation for a client with new-onset dysphagia to prevent aspiration and ensure safe oral intake.

Step-by-Step Solution

1
Analyze the client's clinical presentation and identified deficits.
The client exhibits profound fine motor deficits (inability to grasp utensils) and new-onset dysphagia following a cerebrovascular accident.
Identifying the specific physical and functional deficits is required to determine the appropriate allied health referrals.
2
Evaluate the scope of practice for the interdisciplinary team members.
Occupational therapy is indicated for fine motor deficits and adaptive equipment for activities of daily living. Speech-language pathology is indicated for swallowing evaluations and dysphagia management.
Matching the client's specific functional deficits to the correct interdisciplinary specialty ensures safe and effective care.
3
Analyze the distractors for safety, delegation, and communication errors.
The other options contain critical nursing errors: delegating initial assessments to unlicensed assistive personnel, using non-therapeutic communication, and confusing stroke pathology with normal aging.
Eliminating incorrect actions ensures adherence to safe nursing practice and professional standards.

Key Concept

Interdisciplinary Collaboration and Scope of Practice in Rehabilitation
Question 2344Question →

During interdisciplinary rounds, healthcare teams must navigate complex situations involving client rights, professional duties, and moral obligations. Match each clinical scenario described on the left with the foundational ethical principle it most directly illustrates on the right.

Click a left item, then click its matching right item

Items

Advocating for an undocumented, uninsured client to receive the same comprehensive discharge planning and home health resources as fully insured clients.
Declining a provider's order to administer a dose of chemotherapy that significantly exceeds weight-based guidelines until the rationale is explicitly verified.
Remaining at the bedside to hold the hand of a dying client whose family has not yet arrived, fulfilling a previous commitment made to the client.
Supporting a competent adult with a highly treatable infection who chooses to leave the facility against medical advice (AMA).
Denying a family's request to conceal a terminal diagnosis from a competent client who has explicitly asked for their test results.

Matches

Show answer & explanation

Answer

The correct matching aligns each scenario with its corresponding ethical principle: advocating for equal resources demonstrates justice, questioning an unsafe order demonstrates nonmaleficence, fulfilling a bedside promise demonstrates fidelity, supporting an AMA discharge demonstrates autonomy, and disclosing a terminal diagnosis demonstrates veracity.
Each clinical scenario corresponds precisely to a distinct ethical principle. Justice demands fairness in resource allocation. Nonmaleficence requires nurses to protect clients from harm. Fidelity mandates faithfulness to professional commitments. Autonomy requires respecting a competent client's right to direct their own care. Veracity dictates that nurses must be truthful with clients regarding their health status.

Step-by-Step Solution

1
Analyze the scenario involving the uninsured client and discharge resources.
The nurse is ensuring equal access to care.
This identifies the application of fairness and equity in healthcare delivery, which defines justice.
2
Evaluate the scenario regarding the excessive chemotherapy order.
The nurse is actively preventing potential harm from an overdose.
This aligns with the duty to protect clients from injury or adverse effects, known as nonmaleficence.
3
Review the scenario about remaining at the bedside for a dying client.
The nurse is honoring a commitment made to a vulnerable client.
This reflects the obligation of loyalty and promise-keeping, which is fidelity.
4
Examine the scenario describing the client leaving against medical advice.
The nurse is respecting the client's self-determination.
Competent adults have the right to refuse care, demonstrating the principle of autonomy.
5
Assess the scenario concerning the terminal diagnosis disclosure.
The nurse is prioritizing honesty with the client over the family's wishes.
Clients have a right to truthful information about their own medical condition, representing veracity.

Key Concept

Core Ethical Principles in Nursing Practice
Question 2345Question →

A nurse is caring for a client with advanced heart failure who is participating in a clinical research trial. During the morning assessment, the client states, 'I want to stop taking this experimental drug because the nausea is unbearable, but I am afraid my doctor will be angry and refuse to treat my heart condition.' Which of the following actions should the nurse take to demonstrate ethical practice? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Validate the client's right to withdraw from the research study at any time without penalty; Withhold the experimental medication and notify the healthcare provider; Document the client's concerns and the refusal of the medication in the medical record

Answer

The correct actions are to validate the client's right to withdraw from the study, withhold the experimental medication and notify the provider, and document the client's concerns and refusal.
The nurse acts as a client advocate by upholding the ethical principle of autonomy. When a client expresses a desire to withdraw from a research trial or refuse medication, the ethical nursing actions include validating their right to do so without fear of penalty, withholding the refused treatment, notifying the appropriate healthcare providers, and thoroughly documenting the interaction.

Step-by-Step Solution

1
Identify the primary ethical principles involved in the client's statement.
The scenario highlights autonomy (the right to self-determination) and nursing advocacy.
Understanding the underlying ethical conflict is necessary to select appropriate nursing interventions.
2
Evaluate each option against the principles of ethical nursing practice and therapeutic communication.
Options supporting self-determination and safety are correct, while those involving false reassurance, personal advice, or overriding the client's refusal are incorrect.
Nursing actions must align with the ANA Code of Ethics and legal boundaries for informed consent.
3
Select all interventions that legally and ethically support the client.
Validating the right to withdraw, withholding the refused drug, notifying the provider, and documenting the event are the correct actions.
These actions directly uphold the client's rights without imposing the nurse's values.

Key Concept

Ethical Practice: Client Autonomy and Advocacy in Clinical Research
Question 2346Question →

A 14-year-old client presents to a community health clinic seeking testing for a suspected sexually transmitted infection (STI). During the assessment, the client discloses being sexually active with a 23-year-old acquaintance. The client pleads with the nurse, 'Please do not tell my parents; they will disown me.' Which legally and ethically sound actions should the registered nurse implement? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Proceed with STI testing and treatment based solely on the minor client's consent.; Inform the client that the healthcare team is legally obligated to report the relationship.

Answer

The nurse must proceed with STI testing based on the minor's consent and inform the client of the legal obligation to report the relationship to authorities.
The registered nurse has a legal responsibility to understand minor consent laws and mandatory reporting statutes. In all US states, minors can legally consent to testing and treatment for sexually transmitted infections without parental consent; therefore, the nurse should proceed with the STI care to protect the client's health. Simultaneously, the sexual relationship between a 14-year-old and a 23-year-old constitutes statutory rape. As a mandatory reporter, the nurse is legally obligated to report this to child protective services or law enforcement. Ethically, the nurse must inform the client about this limit to confidentiality rather than deceiving them.

Step-by-Step Solution

1
Evaluate the client's legal right to consent to medical care.
Minors have the legal right to consent to testing and treatment for sexually transmitted infections without parental notification or consent.
Public health laws prioritize treating communicable diseases by removing barriers, such as requiring parental consent, for adolescents seeking care.
2
Analyze the disclosure of sexual activity between a 14-year-old and a 23-year-old.
This age discrepancy constitutes statutory rape, which is a form of child abuse under the law.
Nurses are mandatory reporters and are legally required to report suspected abuse of minors to appropriate state authorities immediately.
3
Determine the appropriate therapeutic communication regarding the breach of confidentiality.
The nurse must honestly inform the client about the legal limits of confidentiality and the mandate to report the relationship.
Maintaining trust and ethical practice requires transparency, even when mandatory reporting supersedes the client's request for secrecy.

Key Concept

Mandatory reporting laws require nurses to report suspected child abuse (including statutory rape) immediately, while minor consent laws allow adolescents to seek confidential treatment for sexually transmitted infections without parental permission.
Question 2347Question →

An older adult client with a new diagnosis of heart failure is being prepared for discharge. The client lives alone on a fixed income, requires eight new daily medications, and does not own a scale for required daily weights. While discussing the transition home, the client begins crying and states, "I cannot afford these pills, and I do not know how I will manage all of this by myself." Which actions demonstrate appropriate interdisciplinary collaboration and care management by the nurse? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Request a consult with the medical social worker to explore medication assistance programs and home healthcare resources.; Refer the client to a registered dietitian for comprehensive meal planning that aligns with a low-sodium diet on a fixed income.; Collaborate with the clinical pharmacist to identify potential ways to simplify the new complex polypharmacy regimen.

Answer

The appropriate interdisciplinary actions are to consult the medical social worker, refer the client to a registered dietitian, and collaborate with the clinical pharmacist.
The client has multifaceted discharge needs that require an interdisciplinary approach. The medical social worker is the correct referral to assist with financial barriers regarding medication affordability and securing medical equipment for the home. The registered dietitian is the correct referral to provide specialized education on maintaining a low-sodium diet while on a fixed income. The clinical pharmacist is the correct referral to review the new eight-medication regimen to identify cost-saving alternatives and simplify the dosing schedule for better adherence.

Step-by-Step Solution

1
Analyze the client's specific discharge barriers presented in the scenario.
The client has financial limitations, requires a complex regimen of 8 new medications, needs a specialized low-sodium diet on a fixed income, lacks necessary equipment (a scale), and exhibits situational anxiety about managing care alone.
Identifying the distinct physiological, financial, and psychosocial barriers determines which specialized interdisciplinary team members are required for a safe discharge.
2
Match each identified barrier with the appropriate allied health professional's scope of practice.
The social worker is needed to address financial and resource needs (medication costs, obtaining a scale). The pharmacist is needed to optimize the complex medication regimen. The dietitian is needed to provide specialized nutritional counseling for a heart failure diet on a budget.
Proper utilization of the interdisciplinary team ensures comprehensive care by leveraging the specific expertise of each discipline.
3
Evaluate the remaining options to eliminate unsafe or non-therapeutic nursing actions.
Delegating teaching to a UAP (improper delegation), providing false reassurance (non-therapeutic communication), and immediately paging the provider for a non-emergent psychosocial issue (improper prioritization) are eliminated.
Nursing actions must remain within legal scopes of practice, utilize therapeutic communication, and reflect proper clinical prioritization.

Key Concept

Effective interdisciplinary collaboration involves partnering with allied health professionals—such as social workers, pharmacists, and dietitians—to comprehensively address complex client needs that extend beyond the immediate nursing scope of practice.
Question 2348Question →

A public health clinic nurse evaluates a client who has just received a confirmed diagnosis of active, multi-drug resistant tuberculosis (MDR-TB). Upon hearing the diagnosis and the requirement for immediate isolation, the client becomes highly agitated, refuses all treatment, and states, 'I am leaving right now. I have a commercial flight in two hours to attend a large indoor convention across the country, and I am not missing it.' The client then explicitly forbids the nurse from sharing their medical information with anyone. In accordance with federal privacy regulations and professional nursing standards, which action should the nurse take regarding the disclosure of the client's protected health information (PHI)?

Show answer & explanation

Answer: Disclose the client's diagnosis and flight intentions to the appropriate public health authorities or law enforcement to mitigate a serious and imminent threat to public safety.

Answer

The nurse must breach confidentiality and report the situation to the appropriate public health authorities or law enforcement to prevent a serious and imminent threat to the public.
The correct action involves disclosing the information to public health authorities. Under the HIPAA Privacy Rule, healthcare providers are legally permitted (and ethically obligated) to disclose protected health information without a client's authorization if they believe in good faith that the disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. Active, multi-drug resistant tuberculosis in a confined commercial flight setting constitutes a severe public health emergency that supersedes the individual's standard right to confidentiality.

Step-by-Step Solution

1
Analyze the client's diagnosis and stated intentions against the risk to public safety.
The client has a highly contagious, airborne, and drug-resistant disease and plans to enter a densely crowded, enclosed environment (a commercial aircraft).
To determine the severity and imminence of the threat posed to the general public.
2
Evaluate the client's explicit demand for confidentiality against federal privacy regulations.
While clients generally possess the right to privacy, the Health Insurance Portability and Accountability Act (HIPAA) contains specific exemptions for public health emergencies and imminent threats.
To identify if a legal and ethical exception overrides the client's refusal to consent to information sharing.
3
Determine the most appropriate and legally compliant course of action.
The nurse must immediately disclose the minimum necessary protected health information to individuals or authorities reasonably able to prevent the threat.
To uphold the ethical and legal duty to protect the public from severe, preventable harm.

Key Concept

HIPAA exceptions for imminent threats to public safety and mandatory reporting
Question 2349Question →

A 45-year-old client is in the preoperative staging area prior to an elective cervical laminectomy. When the registered nurse (RN) provides the consent form for signature, the client hesitates and states, "I do not think I am ready to sign this. I still have a lot of questions about what my mobility will be like after the surgery." Arrange the following nursing actions in the correct priority order.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first stop the signing process, then assess the client's specific concerns, reassure them of their right to delay the procedure, notify the surgeon to provide clarification, and finally document the event.
The correct sequence follows the nursing process and legal principles of informed consent. First, the RN must immediately halt the process to prevent an invalid consent from being signed. Second, the RN assesses the client's specific concerns to understand the knowledge deficit. Third, the RN advocates for the client by reassuring them of their right to delay the procedure. Fourth, the RN notifies the surgeon, as it is the provider's legal duty to explain procedural risks and outcomes. Finally, the RN documents the entire interaction and the notification of the provider.

Step-by-Step Solution

1
Stop the consent signing process.
Prevents the execution of an invalid informed consent.
A client who expresses doubt or lack of understanding cannot legally give informed consent.
2
Ask the client to explain their specific concerns about postoperative mobility.
Identifies the exact nature of the client's knowledge deficit.
Assessment is the first step of the nursing process and is required before formulating a plan or contacting the provider.
3
Reassure the client that they have the right to delay the surgery until their questions are answered.
Validates the client's feelings and protects their rights.
The nurse acts as an advocate to ensure the client does not feel pressured into signing.
4
Notify the surgeon that the client requires further clarification about the procedure.
Escalates the issue to the appropriate provider.
Answering specific questions about surgical risks and outcomes is the legal responsibility of the performing provider, not the RN.
5
Document the client's exact statements and the notification of the surgeon in the medical record.
Creates a permanent legal record of the event.
Documentation is always the final step after assessing, intervening, and evaluating a clinical situation.

Key Concept

The RN's role in informed consent is to act as a witness and advocate. When a client expresses a lack of understanding, the RN must halt the process, assess concerns, and notify the primary healthcare provider to provide clarification.
Question 2350Question →

During a shift, a client receiving intravenous antibiotics for bacterial endocarditis unplugs their IV pump, gets dressed, and announces they are going home immediately due to frustration with the hospital environment. The client is awake, alert, and fully oriented to person, place, time, and situation. Which of the following is the most appropriate legal and ethical nursing action?

Show answer & explanation

Answer: Discuss the potential risks of leaving without completing the antibiotic treatment and prepare an against medical advice (AMA) document.

Answer

Discuss the potential risks of leaving without completing the antibiotic treatment and prepare an against medical advice (AMA) document.
The correct action respects the legal right of a competent adult to refuse treatment and leave the healthcare facility. The nurse's responsibility is to ensure the client is fully informed of the potential medical consequences (e.g., worsening infection, sepsis, or death) and to document the client's informed refusal via an AMA form.

Step-by-Step Solution

1
Assess the client's competency and mental status.
The client is awake, alert, and fully oriented, indicating they are legally competent to make healthcare decisions.
Only legally competent clients have the right to refuse treatment and leave against medical advice (AMA).
2
Identify the legal boundaries regarding client autonomy.
The client has the right to refuse care. Forcing them to stay would constitute false imprisonment.
Nurses must advocate for and respect a competent client's autonomy, even when the client's choices are medically inadvisable.
3
Implement the appropriate AMA protocol.
The nurse explains the medical risks of untreated endocarditis and asks the client to sign the AMA form.
This action protects the client's legal rights while also providing informed consent regarding the risks of leaving, protecting the healthcare facility from liability.

Key Concept

Client Autonomy and Right to Refuse Treatment
Question 2351Question →

A nurse is assigned to care for a newly admitted client who recently traveled internationally and presents with a severe acute respiratory infection, fever, and a persistent cough. The client has a suspected case of Middle East Respiratory Syndrome (MERS) and requires concurrent airborne and contact precautions. The nurse has gathered all required supplies in the anteroom outside the client's negative-pressure isolation room. Arrange the following actions in the correct sequence for donning personal protective equipment (PPE) before entering the client's room.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence for donning PPE is: perform hand hygiene, put on the isolation gown, don the N95 respirator, apply the face shield, and finally put on the gloves.
The correct sequence for donning PPE ensures that the healthcare worker builds their protective barrier systematically without contaminating the gear. Hand hygiene must occur first to ensure clean hands are manipulating the clean PPE. The gown is applied first due to its bulk and the need to secure ties behind the back. The N95 respirator is applied and sealed next because it must sit directly on the face and head for an airtight fit. This is followed by the face shield, which protects both the eyes and the exterior of the respirator. Gloves are applied last so they can be stretched over the cuffs of the gown, establishing a continuous, unbroken barrier necessary for contact precautions.

Step-by-Step Solution

1
Perform hand hygiene.
Hands are rendered clean and free of transient pathogens.
This establishes a clean baseline, preventing the transfer of microorganisms to the clean PPE during the donning process.
2
Put on the isolation gown.
The nurse's torso and arms are fully covered, and ties are secured.
The gown's ties require fine motor skills that are easiest to manage before donning gloves.
3
Don the N95 respirator and perform a seal check.
The respirator is properly fitted, creating an airtight seal over the nose and mouth.
Applying the respirator before eye protection ensures the straps are positioned correctly without obstruction, offering optimal protection against airborne particles.
4
Place the face shield.
The eyes and the exterior of the respirator are shielded.
The shield provides a barrier against droplets and splashes, sitting comfortably over the pre-secured respirator.
5
Put on gloves, pulling them over the gown cuffs.
Hands and wrists are fully protected by a continuous barrier.
Pulling the gloves over the cuffs seals the potential gap at the wrists, completing the required contact precautions.

Key Concept

The CDC standard sequence for donning personal protective equipment ensures maximum barrier protection and prevents inadvertent contamination of the equipment prior to entering an isolation environment.
Question 2352Question →

A registered nurse begins a shift on a pediatric unit and reviews the current status of assigned clients. Which client requires immediate assessment by the nurse?

Show answer & explanation

Answer: A 6-year-old who underwent a tonsillectomy earlier in the day and is observed swallowing frequently

Answer

The 6-year-old who underwent a tonsillectomy and is swallowing frequently requires the most immediate assessment.
Frequent or continuous swallowing in a client who recently had a tonsillectomy is a subtle but critical sign of active bleeding in the surgical area. This bleeding poses an immediate threat to the client's airway and circulation, making it a medical emergency that requires priority assessment and intervention.

Step-by-Step Solution

1
Analyze each client's condition using the Airway-Breathing-Circulation (ABC) framework and the concept of expected versus unexpected findings.
The post-tonsillectomy client has a potential airway and circulation compromise, while the other clients present with expected disease manifestations.
Prioritization questions require identifying the client with the most acute, life-threatening, or unstable condition.
2
Evaluate the clinical significance of frequent swallowing in a postoperative tonsillectomy client.
Frequent swallowing indicates blood trickling down the throat, which is a key sign of active postoperative hemorrhage.
Hemorrhage can rapidly lead to airway obstruction or hypovolemic shock, establishing this client as the highest priority.

Key Concept

Prioritization relies on the ABC (Airway, Breathing, Circulation) framework, addressing unexpected, acute, or life-threatening complications before managing expected disease manifestations or basic comfort needs.
Question 2353Question →

A registered nurse is coordinating a home hospice transition plan for a client with late-stage amyotrophic lateral sclerosis (ALS). The client has recently developed episodes of coughing during meals, profound upper extremity weakness, and the spouse reports severe exhaustion from providing continuous care. Which of the following interdisciplinary team actions should the nurse include in the care plan? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Initiate a referral to speech-language pathology for a comprehensive dysphagia evaluation and dietary texture recommendations.; Engage medical social services to evaluate the spouse for caregiver burnout and arrange supplemental in-home support.; Involve occupational therapy to assess fine motor deficits and provide adaptive devices that promote safe self-care.

Answer

The appropriate interdisciplinary actions are initiating a referral to speech-language pathology, engaging medical social services, and involving occupational therapy.
The client requires a comprehensive interdisciplinary approach to address multifaceted palliative needs. A speech-language pathologist is necessary to evaluate the new-onset coughing and recommend strategies to prevent aspiration. An occupational therapist is needed to address the profound upper extremity weakness and provide adaptive devices for daily living. Additionally, a medical social worker must be involved to support the exhausted spouse, evaluate caregiver burnout, and arrange for community respite care resources.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
Identifies multiple complex needs including new-onset coughing during meals (airway risk), upper extremity weakness (ADL impairment), and caregiver exhaustion (psychosocial need).
Understanding the holistic needs of the client determines which specialized allied health professionals to involve in the transition plan.
2
Evaluate the specific roles of interdisciplinary team members.
Matches speech-language pathology with dysphagia management, occupational therapy with fine motor support and adaptive devices, and social services with caregiver strain and resource management.
Appropriate collaboration requires accurate knowledge of each discipline's legal and clinical scope of practice.
3
Apply principles of prioritization and delegation to eliminate inappropriate actions.
Recognizes that airway concerns must be prioritized over mobility training, and that initial assessment of a new symptom cannot be delegated to a UAP.
Ensures adherence to the ABC framework (Airway, Breathing, Circulation) and safe delegation guidelines.

Key Concept

Interdisciplinary Collaboration and Scope of Practice
Question 2354Question →

A 42-year-old client in the intensive care unit is mechanically ventilated for acute respiratory failure. The client suddenly develops severe hyperactive delirium, aggressively attempting to self-extubate and physically striking nursing staff. Following unsuccessful pharmacological and environmental de-escalation attempts, the healthcare provider prescribes bilateral wrist and ankle restraints for the management of violent behavior. Which of the following nursing interventions are appropriate for this client? Select all that apply.

Select all that apply

Show answer & explanation

Answer: Ensure a healthcare provider performs a face-to-face evaluation of the client within 1 hour of initiating the restraints.; Document the specific aggressive behaviors exhibited by the client and the ineffectiveness of prior de-escalation measures.; Maintain continuous in-person observation or dedicated audio and video monitoring of the client for the duration of the restraint use.

Answer

The correct interventions include obtaining a face-to-face provider evaluation within 1 hour, maintaining continuous observation, and documenting the specific behaviors along with failed de-escalation attempts.
When restraints are applied for the management of violent or self-destructive behavior, strict regulatory standards apply to ensure patient and staff safety. These include a mandatory face-to-face provider evaluation within 1 hour, continuous in-person or direct audio/video monitoring, and meticulous documentation of the specific dangerous behaviors alongside the failure of less restrictive interventions. These measures mitigate the high risk of severe physical or psychological harm associated with behavioral emergencies.

Step-by-Step Solution

1
Identify the type of restraint protocol indicated by the clinical scenario.
The client is exhibiting violent, self-destructive behavior (striking staff, pulling life-support), which falls under strict behavioral/violent restraint regulations rather than standard medical-surgical restraint rules.
Different restraint indications have vastly different regulatory timeframes and monitoring requirements for safety.
2
Evaluate the regulatory timeframes for violent restraints.
Violent restraints require a face-to-face provider evaluation within 1 hour and clinical assessments at least every 15 minutes, making the 2-hour assessment interval incorrect.
Violent restraints pose a significantly higher risk of physical harm and psychological trauma, necessitating intensive oversight.
3
Apply general restraint safety and delegation principles.
Restraints must be tied to the movable bed frame (not side rails), and removing them for an unstable, agitated client on a ventilator cannot be delegated to a UAP.
Tying to side rails risks severe musculoskeletal injury. Delegating complex airway risk management exceeds the UAP scope of practice.
4
Select the evidence-based, legally compliant interventions.
The appropriate actions are ensuring the 1-hour provider evaluation, documenting behaviors and failed alternatives, and maintaining continuous observation.
These actions perfectly align with evidence-based safety guidelines for violent behavioral restraints.

Key Concept

Nursing Management of Violent Behavioral Restraints
Question 2355Question →

The registered nurse (RN) is planning care for a client who sustained an ischemic stroke 48 hours ago and has new-onset right-sided hemiparesis and dysphagia. Which of the following tasks can the RN safely delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

Select all that apply

Show answer & explanation

Answer: Perform passive range-of-motion (ROM) exercises on the affected extremities.; Empty the indwelling urinary catheter drainage bag and record the volume.; Apply a moisture barrier cream to the client's intact sacral skin.

Answer

The tasks that can be safely delegated include performing passive range-of-motion exercises, emptying and recording catheter output, and applying moisture barrier cream to intact skin.
According to the principles of safe delegation, the RN can delegate routine, standard tasks with predictable outcomes to the UAP. Performing passive range-of-motion exercises, measuring output from an indwelling catheter, and applying moisture barrier cream to intact skin are all standard activities of daily living (ADLs) and basic care tasks. They do not require nursing assessment, clinical judgment, or evaluation.

Step-by-Step Solution

1
Analyze the client's current status and potential for harm.
The client is 48 hours post-stroke with hemiparesis and a new diagnosis of dysphagia, placing them at high risk for aspiration.
Safe delegation requires ensuring the client is stable enough for standard care without requiring continuous assessment during the task.
2
Evaluate each task against the legal scope of practice for a UAP.
Tasks that require clinical assessment, nursing judgment, evaluation, or client teaching must be excluded.
The RN is legally accountable for the nursing process and cannot delegate 'EAT' (Evaluate, Assess, Teach).
3
Select the standard, routine tasks with predictable outcomes.
Performing ROM, recording urinary output, and applying topical barrier cream to intact skin are appropriate to delegate.
These tasks involve basic hygiene, mobility, and data gathering, which do not require independent clinical decision-making.

Key Concept

Delegation of tasks to unlicensed assistive personnel (UAP) must exclude the nursing process (assessment, planning, evaluation) and health teaching. Tasks involving high-risk clients (e.g., initial feeding with dysphagia) must remain with the RN.
Question 2356Question →

A nurse enters a client's room and finds the client lying on the floor near the bathroom door. In what order should the nurse perform the following actions? Arrange the steps in the correct sequence from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence is to first assess the client for injuries, then obtain help to move the client safely back to bed, notify the provider, and finally complete the administrative incident report.
The nursing process dictates that assessment must always come first. By assessing the client immediately on the floor, the nurse ensures it is safe to move them. Getting assistance guarantees a safe transfer. Provider notification follows securing the patient to manage any medical consequences. Finally, the incident report is an administrative duty that concludes the post-fall protocol.

Step-by-Step Solution

1
Assess the client for injuries and check vital signs
Determines if it is safe to move the client
Patient safety and assessment are the absolute first priorities in any emergency or fall scenario before any interventions are taken.
2
Call for help and transfer the client to bed
Client is safely secured in a therapeutic environment
Moving a patient from the floor requires assistance to prevent further harm to both the client and the nursing staff.
3
Notify the healthcare provider
Provider is updated on the client's status
Medical evaluation or new diagnostic orders may be required based on the circumstances of the fall.
4
Complete an incident report
The event is formally documented for facility quality improvement
Administrative documentation is always the final step after direct clinical care and safety needs are met.

Key Concept

Post-Fall Management and Nursing Prioritization
Question 2357Question →

A registered nurse receives a telephone call at the nurses' station from an individual claiming to be the spouse of a client who recently returned from surgery. The caller requests an update on the client's clinical condition. In what order should the nurse perform the following actions to ensure compliance with confidentiality and information security protocols? Arrange the steps from first to last.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence prioritizes preventing immediate unauthorized disclosure, verifying legal permission, authenticating identity, ensuring environmental privacy, and finally documenting the encounter.
This sequence adheres to strict HIPAA and HITECH standards by establishing a systematic barrier to unauthorized disclosure. Preventing initial confirmation protects the client's presence, while checking the record and verifying the passcode ensures legal authorization and identity authentication before any clinical data is shared.

Step-by-Step Solution

1
Place the caller on hold without confirming admission.
The caller is paused, and the client's presence remains confidential.
Prevents inadvertent disclosure of the client's admission status to an unverified caller.
2
Review the EHR for authorization.
The nurse confirms if the spouse is legally allowed to receive information.
Ensures the nurse is legally permitted to share PHI with this specific individual.
3
Verify identity using a passcode.
The caller proves they are the authorized spouse.
Authenticates the identity of the person on the phone to prevent social engineering breaches.
4
Move to a private area.
The nurse is in a secure location to talk.
Prevents incidental eavesdropping by unauthorized persons in the hallway or nurses' station.
5
Document the interaction.
The EHR is updated with the disclosure details.
Provides a required legal audit trail of the PHI disclosure.

Key Concept

HIPAA Compliance During Telephone Disclosures of Protected Health Information (PHI)
Question 2358Question →

An emergency department nurse is providing care for a competent adult client who has sustained multiple facial and rib fractures. While the client's partner is temporarily out of the treatment room, the client tearfully discloses, "My partner did this to me. You cannot tell the police, or my partner will kill me." Based on the ethical principles of autonomy and confidentiality, which of the following is the most appropriate action for the nurse to take?

Show answer & explanation

Answer: Provide the client with information about domestic violence support services and collaborate to create a personal safety plan.

Answer

The most appropriate action is to provide the client with information about domestic violence support services and collaborate to create a personal safety plan, respecting their autonomy and request for confidentiality.
For competent adult clients experiencing intimate partner violence (IPV), the ethical principles of autonomy and confidentiality supersede the principle of beneficence (the desire to protect from harm). Unless there is a specific legal mandate (such as involvement of a vulnerable population like a child or elder, or a specific weapon-related injury mandate depending on jurisdiction), the nurse must respect the client's right to self-determination. The correct nursing action is to offer support, provide resources for safe shelters, and assist with safety planning, which empowers the client to make their own decisions without breaching their trust or inadvertently escalating their risk.

Step-by-Step Solution

1
Analyze the client's clinical and legal status.
The client is a competent adult who is experiencing intimate partner violence (IPV) and has explicitly requested that authorities not be notified.
Determining competency is essential for establishing whether the client retains the right to autonomous decision-making.
2
Evaluate the ethical conflict between principles.
There is a conflict between beneficence (the desire to protect the client from harm) and the principles of autonomy (the client's right to choose) and confidentiality (keeping health information private).
Ethical nursing practice requires weighing competing principles to determine the legally and morally correct course of action.
3
Apply legal and ethical standards for mandatory reporting.
Unlike cases involving children, elders, or cognitively impaired individuals, competent adults in IPV situations are generally not subject to mandatory reporting laws for assault. Autonomy and confidentiality must prevail.
Violating confidentiality without a legal mandate can destroy the therapeutic relationship and potentially place the client in greater danger from the abuser.

Key Concept

Ethical Practice: Autonomy and Confidentiality in Intimate Partner Violence
Question 2359Question →

A registered nurse is caring for an adult client with severe gastrointestinal bleeding who has been prescribed an emergency packed red blood cell (PRBC) transfusion. The client states, 'I cannot accept blood products due to my religious beliefs.' Arrange the following nursing actions in the correct legal and procedural sequence.

Drag items to arrange them in the correct order

Show answer & explanation

Answer

The correct sequence begins with assessing the client's rationale, followed by notifying the healthcare provider. Next, the provider must explain the medical risks of refusal, after which the nurse witnesses the signature on the legal refusal form. Finally, the entire event is documented in the medical record.
The sequence follows the logical progression of protecting client rights while adhering to legal facility protocols. First, the nurse assesses to ensure the client is competent and the refusal is resolute. Second, the provider is notified to intervene. Third, the provider must legally disclose the clinical risks of refusal. Fourth, after being fully informed, the client signs the legal liability waiver, which the nurse witnesses. Finally, the nurse documents the entire objective encounter in the medical record to establish a legal defense of the team's actions.

Step-by-Step Solution

1
Assess the client's understanding and rationale.
The nurse confirms the refusal is based on religious beliefs and assesses the client's competency.
The nursing process dictates assessment as the initial action to validate the client's intent and establish the context of the refusal.
2
Notify the attending healthcare provider.
The provider is made aware of the critical change in the treatment plan.
Prompt communication is legally required so the provider can address the life-threatening situation and explore non-blood alternatives.
3
Ensure the provider explains the clinical risks.
The client receives full disclosure regarding the consequences of not receiving the blood transfusion.
Legally, the prescribing provider holds the responsibility to disclose the medical risks associated with refusing a life-saving intervention.
4
Witness the signature on the refusal waiver.
A legally binding liability release form is executed.
The waiver protects the healthcare facility from liability and formally documents the client's informed right to self-determination.
5
Document the sequence of events.
The electronic health record reflects a comprehensive account of the refusal process.
Timely and accurate documentation serves as the final legal record of the care provided and the protection of client rights.

Key Concept

Client Self-Determination and Informed Refusal Process
Question 2360Question →

A client is admitted to the inpatient psychiatric unit with active suicidal ideation. An individual claiming to be the client's employer calls the nursing station, demanding to know if the client is hospitalized so they can arrange for immediate shift coverage. The client has not authorized any release of information. Which of the following is the most appropriate action by the registered nurse?

Show answer & explanation

Answer: State to the caller, "I cannot confirm or deny the presence of any client in our facility."

Answer

The nurse should state that they can neither confirm nor deny the presence of any client in the facility.
Under the Health Insurance Portability and Accountability Act (HIPAA), a client's presence in a healthcare facility is considered protected health information (PHI). Because the client has not authorized the release of information, the nurse is legally obligated to refuse to confirm or deny the client's admission. This standardized phrase prevents any inadvertent disclosure.

Step-by-Step Solution

1
Evaluate the caller's request against HIPAA regulations and facility policy.
The caller is asking for protected health information (PHI) regarding the client's admission status.
Any disclosure of PHI requires explicit authorization from the client, unless a specific legal exception applies.
2
Verify if the client has provided authorization to share information with this specific caller.
The client has not authorized any release of information.
Without a signed release, no information, including the mere fact that the client is admitted, can be shared.
3
Formulate a response that strictly adheres to privacy laws without providing inadvertent confirmation.
The nurse uses the standard protocol of refusing to confirm or deny the client's presence.
This standardized statement protects confidentiality while providing a professional boundary to the unauthorized caller.

Key Concept

Under HIPAA regulations, a nurse must not disclose any protected health information (PHI), including confirming a client's admission or presence in a facility, without explicit authorization from the client.
PreviousPage 118 / 195Next
All practice questions — NCLEX-RN | Examkin