Examkin

Tüm alıştırma soruları

3881 soru

Tüm türler3,881Çoktan seçmeli1,926Çoklu seçim908Sayısal119Eşleştirme66Sıralama862
Soru 2021Soru →

An adult client is receiving continuous intravenous (IV) antibiotics for severe cellulitis. The client, who is alert, oriented, and demonstrates clear decision-making capacity, abruptly disconnects the IV tubing and states, "I am tired of this hospital. I am leaving right now." The client's adult child privately approaches the nurse and says, "Please give my parent the PRN lorazepam that was ordered for anxiety. If they fall asleep, they will stay and finish the treatment. They are just overwhelmed."

Which of the following is the most appropriate, legally sound action for the nurse to take?

Cevabı ve açıklamayı göster

Cevap: Inform the adult child that using medication to detain a competent client is unlawful, and initiate the against medical advice (AMA) discharge process.

Cevap

The correct action is to inform the adult child that using medication to detain a competent client is unlawful, and to initiate the against medical advice (AMA) discharge process directly with the client.
The correct action upholds the legal principle of autonomy. A competent client has the absolute right to refuse treatment and leave a healthcare facility against medical advice (AMA). Administering a medication specifically to sedate a client and prevent them from leaving is legally defined as a chemical restraint and false imprisonment. The nurse must firmly explain this legal boundary to the family member and proceed with standard AMA protocols, which includes having the RN directly explain the risks of leaving to the client.

Adım Adım Çözüm

1
Assess the client's decision-making capacity and legal rights.
The client is alert, oriented, and competent, granting them the legal right to refuse treatment and leave the hospital.
Competent adults have the right to self-determination regarding their healthcare, even if their decisions pose a risk to their health.
2
Evaluate the adult child's request to administer a sedative.
The request violates the client's legal rights, as using medication to prevent a competent client from leaving constitutes a chemical restraint and false imprisonment.
Medications cannot be used for the convenience of staff or family to restrict a client's freedom of movement or alter their behavior to force compliance.
3
Determine the legally sound nursing intervention.
The nurse must educate the family member about legal boundaries and proceed with the AMA protocol, ensuring the RN personally explains the medical risks to the client.
The nurse's legal and ethical duty is to advocate for the client's autonomy while ensuring they are fully informed of the consequences of their actions.

Anahtar Kavram

Client Autonomy, Chemical Restraints, and AMA Protocols
Tahmini Süre:1m 30s
Soru 2022Soru →

An emancipated 17-year-old is at an outpatient oncology center awaiting a bone marrow aspiration. While reviewing the paperwork, the adolescent pauses and asks the nurse, 'The doctor mentioned infection and bleeding as possible problems, but I read online that this could damage my spine. Is that true? I never got to ask.' What is the most appropriate action for the nurse to take?

Cevabı ve açıklamayı göster

Cevap: Suspend the consent process and page the healthcare provider to answer the client's questions about spinal damage.

Cevap

The most appropriate action is to suspend the consent process and page the healthcare provider to answer the client's questions about spinal damage.
The correct action reflects the nurse's fundamental role as a client advocate and a witness to informed consent. Because the client has unanswered questions about potential procedural complications, they are not fully informed. The registered nurse cannot legally explain the medical risks of a surgical or invasive procedure, as this falls under the healthcare provider's scope of practice. Therefore, the nurse must halt the signature process and notify the provider to return and properly address the client's concerns.

Adım Adım Çözüm

1
Evaluate the client's legal status and readiness to sign the consent form.
The emancipated minor has the legal authority to consent, but demonstrates a lack of understanding regarding the procedure's risks.
Informed consent requires the client to fully comprehend the risks, benefits, and alternatives prior to signing.
2
Identify the boundaries of the registered nurse's scope of practice.
The nurse determines that providing detailed medical explanations about procedural risks falls outside the RN scope.
The healthcare provider performing the procedure holds the legal responsibility for explaining risks and answering specific medical questions.
3
Intervene to protect the client's legal rights and safety.
The nurse stops the consent process and contacts the provider to return to the room.
The nurse acts as a client advocate to ensure that informed consent is both valid and voluntary.

Anahtar Kavram

The nurse's role in informed consent is to act as a witness and advocate, ensuring the client is legally competent and fully understands the procedure, while deferring all medical explanations to the healthcare provider.
Soru 2023Soru →

While working on a busy pediatric unit, a nurse is determining the order of initial client assessments. Which client should the nurse assess first?

Cevabı ve açıklamayı göster

Cevap: A 6-year-old client who is 6 hours postoperative following a tonsillectomy and is observed swallowing frequently

Cevap

The 6-year-old client who is 6 hours postoperative following a tonsillectomy and is observed swallowing frequently.
Post-tonsillectomy, frequent or continuous swallowing is a primary indicator of active bleeding in the surgical site, as the client is unconsciously swallowing trickling blood. This presents an immediate threat to both circulation (hypovolemia) and the airway (aspiration or obstruction). This client is experiencing an unexpected, life-threatening emergency and must be assessed first.

Adım Adım Çözüm

1
Analyze each client's condition using the Airway, Breathing, and Circulation (ABC) framework.
The post-tonsillectomy client exhibits a sign of potential airway compromise and circulatory volume loss.
Airway and circulation issues are the highest physiological priorities in client care.
2
Differentiate between expected disease manifestations and unexpected acute complications.
The clients with sickle cell anemia, glomerulonephritis, and bronchiolitis are displaying expected signs of their respective conditions. The post-tonsillectomy client is displaying an unexpected complication.
Unexpected findings, especially those indicating physiological deterioration, take priority over expected chronic or acute manifestations.
3
Identify the client requiring the most immediate intervention.
The post-tonsillectomy client must be assessed first to evaluate for hemorrhage and secure the airway.
Hemorrhage is a life-threatening emergency that rapidly compromises the ABCs.

Anahtar Kavram

Prioritization using the ABC framework and expected versus unexpected clinical findings
Soru 2024Soru →

A nurse is managing the care of a client with a severe exacerbation of myasthenia gravis. The client is experiencing new-onset choking when drinking liquids, profound upper extremity weakness preventing self-feeding, and significant anxiety regarding the financial burden of a potential long-term care placement. Which interdisciplinary actions should the nurse include in the client's plan of care? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Initiate an urgent referral to a speech-language pathologist (SLP) to evaluate the client's swallowing and aspiration risk.; Request a consultation with a social worker to assist the family with long-term care planning and financial resources.; Collaborate with an occupational therapist (OT) to assess the client's ability to perform activities of daily living and recommend adaptive equipment.

Cevap

The correct actions include initiating an SLP referral for the swallowing evaluation, consulting a social worker for financial and placement planning, and collaborating with an OT for ADL assessment and adaptive equipment.
The correct referrals address the client's specific multidimensional needs within the appropriate scopes of practice. A speech-language pathologist specializes in evaluating and managing dysphagia and aspiration risk. A social worker or case manager is equipped to navigate healthcare financing and long-term care placements. An occupational therapist focuses on improving fine motor skills and providing adaptive devices to maximize independence in activities of daily living (ADLs).

Adım Adım Çözüm

1
Analyze the client's multifaceted clinical presentation.
The client presents with a physiological airway/swallowing compromise (choking), a functional deficit (upper extremity weakness affecting self-feeding), and a psychosocial need (anxiety regarding finances and placement).
Identifying specific deficits is the first step in determining which interdisciplinary team members are required.
2
Match the identified clinical deficits to the appropriate interdisciplinary team members' scopes of practice.
Choking requires a Speech-Language Pathologist (SLP); upper extremity weakness and ADL impairment require an Occupational Therapist (OT); financial and placement anxiety requires a Social Worker.
Operating within each discipline's specialized scope of practice ensures safe, comprehensive, and effective care coordination.
3
Evaluate the remaining options based on safety, prioritization, and communication standards.
Delegating the feeding of an unstable client is unsafe; delaying an airway assessment for a financial meeting violates the ABCs; and guaranteeing financial outcomes constitutes false reassurance.
Safe nursing practice requires strict adherence to delegation rules, Maslow's hierarchy of needs, and therapeutic communication principles.

Anahtar Kavram

Interdisciplinary Collaboration, Prioritization, and Delegation
Soru 2025Soru →

A registered nurse is caring for a competent adult client who is receiving intravenous (IV) antibiotics for bacterial pneumonia. The client suddenly packs their belongings, states they are missing an important family event, and declares they are leaving the hospital immediately. Arrange the following nursing actions in the correct chronological order to handle this against medical advice (AMA) event safely and legally.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence is to first assess the client's reasons, then explain the health risks, notify the healthcare provider, have the client sign the official AMA form, and finally remove the IV and provide discharge instructions.
The correct chronological sequence aligns with the nursing process and legal requirements for informed refusal. The nurse must first assess the 'why' (assessment), educate the client on the dangers (implementation), collaborate with the provider to ensure medical risks are explained (collaboration), secure legal documentation of the refusal (documentation), and finally provide safe termination of care (safe practice).

Adım Adım Çözüm

1
Inquire about the client's specific reasons for wanting to leave.
The nurse understands the root cause of the client's desire to leave.
Basic nursing process dictates assessing the situation first, as the nurse may be able to intervene and resolve the issue (e.g., managing pain, contacting family) so the client stays.
2
Discuss the potential health risks and complications.
The client is fully informed about the dangers of leaving.
Nurses have a legal obligation to ensure clients understand the consequences of their actions before they refuse life-saving or necessary medical treatment.
3
Notify the primary healthcare provider.
The provider is aware and can speak to the client.
The healthcare provider is legally responsible for the medical treatment plan and must be given the opportunity to discuss the medical risks of leaving with the client.
4
Request the client to sign the AMA document.
Legal documentation of the client's informed refusal is secured.
This document protects the healthcare team and the facility from legal liability if the client suffers adverse health outcomes after leaving.
5
Remove the IV access and provide discharge instructions.
The client leaves the facility safely.
Clients retaining decision-making capacity have the right to leave at any time; the nurse must still practice safely by removing invasive devices and offering discharge education.

Anahtar Kavram

Against Medical Advice (AMA) Legal Procedures
Tahmini Süre:1m 0s
Soru 2026Soru →

A client is scheduled to be discharged tomorrow following an acute myocardial infarction. While reviewing the new prescription regimen, the client becomes visibly upset and states, 'I have no health insurance and there is no way I can pay for these blood thinners.' Which action by the registered nurse is the most appropriate?

Cevabı ve açıklamayı göster

Cevap: Contact case management to evaluate the client for available medication assistance programs.

Cevap

The most appropriate action is to contact case management to evaluate the client for available medication assistance programs.
Collaborating with case management or social services is the optimal action. These interdisciplinary team members possess specialized knowledge of patient assistance programs, financial resources, and community support systems to help uninsured clients obtain essential discharge medications.

Adım Adım Çözüm

1
Analyze the client's statement to identify the primary barrier to a safe discharge.
The client has a critical financial barrier preventing access to life-saving medications.
Identifying the core issue determines which nursing intervention is required next.
2
Determine which interdisciplinary team member is best equipped to resolve financial and access barriers.
Case management or social services are the experts in navigating healthcare costs and community resources.
Effective interprofessional collaboration ensures the client receives specialized assistance outside the direct scope of bedside nursing.
3
Initiate a referral or consultation.
The nurse contacts case management to step in and assist the client.
Prompt referral ensures the barrier is addressed before the scheduled discharge time.

Anahtar Kavram

Collaboration with Interdisciplinary Team
Soru 2027Soru →

During a high-volume shift in an emergency department observation unit, a nurse is coordinating care with an unlicensed assistive personnel (UAP). Which of the following tasks should the nurse delegate to the UAP? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Obtaining the final set of vital signs for a client who sustained a minor concussion and is awaiting discharge instructions; Assisting a client who has a stable, non-surgical pelvic fracture onto a fracture bedpan; Reattaching a continuous pulse oximetry sensor that slipped off the finger of a sleeping client with asthma

Cevap

The nurse should delegate obtaining vital signs on the discharge-ready client, assisting the stable client onto the fracture bedpan, and reattaching the pulse oximetry sensor.
The correct selections represent standard, repetitive tasks that have predictable outcomes and do not require independent nursing judgment. Obtaining vital signs on a stable client ready for discharge, assisting a stable client with basic elimination needs, and reattaching a non-invasive monitor are all safely within the UAP's scope of practice.

Adım Adım Çözüm

1
Analyze the clinical stability of each client presented in the scenario.
Identify that the client awaiting discharge, the client with a stable pelvic fracture, and the sleeping asthma client are clinically stable. The restless, diaphoretic client with a chest contusion is unstable.
Delegation requires the 'Right Circumstance.' Unstable clients require continuous monitoring and assessment by a registered nurse.
2
Evaluate the nature of each task against the registered nurse's scope of practice.
Identify that demonstrating elevation is 'teaching' and palpating the suprapubic area is 'assessment'.
According to national delegation guidelines, the RN cannot delegate Evaluation, Assessment, or Teaching (EAT).
3
Select the tasks that are safe and legally permissible for the UAP.
Select the routine vital signs, bedpan assistance, and sensor reattachment.
These are standard, repetitive tasks with predictable outcomes performed on stable clients, fitting the UAP scope of practice perfectly.

Anahtar Kavram

Delegation to Unlicensed Assistive Personnel (UAP)
Soru 2028Soru →

A charge nurse in a long-term rehabilitation facility is directing the daily activities of the nursing staff. Which of the following tasks can be safely assigned to the unlicensed assistive personnel (UAP)? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Ambulating a client who is two days post-operative and has a steady gait; Documenting the total volume of fluid consumed by a client during breakfast; Assisting a client with hemiparesis to put on a clean hospital gown

Cevap

Ambulating a steady post-operative client, documenting fluid volume consumed, and assisting a client with hemiparesis to dress.
The appropriate tasks for a UAP involve routine, predictable care for stable clients. Assisting with dressing, ambulating a steady client, and recording oral fluid intake are all safe, standard procedures that do not require nursing judgment.

Adım Adım Çözüm

1
Identify the role and scope of practice of the unlicensed assistive personnel (UAP).
The UAP scope includes basic care, activities of daily living (ADLs), and routine data collection on stable clients.
Understanding scope of practice ensures tasks are assigned safely and legally.
2
Recall the non-delegable nursing tasks.
Registered nurses must not delegate evaluation, assessment, or teaching.
These tasks require clinical judgment and advanced nursing knowledge.
3
Evaluate each task against the UAP's scope of practice.
Tasks involving ambulation, documenting intake, and assisting with gowns are standard and do not require clinical judgment. Tasks involving instruction, evaluating respiratory status, and conducting admission interviews violate delegation principles.
Applying the rules of delegation isolates the safe and appropriate choices.

Anahtar Kavram

Delegation of tasks to unlicensed assistive personnel (UAP) must be limited to standard, unchanging procedures that do not require clinical judgment, assessment, teaching, or evaluation.
Soru 2029Soru →

An 82-year-old alert and oriented client with end-stage heart failure informs the nurse, "I do not want to take my heart medications anymore. I just want to be kept comfortable." The client's adult child is visibly upset and demands that the nurse administer the medications anyway, stating, "My parent is just confused because of their age." Which action by the nurse represents the most appropriate ethical and legal practice?

Cevabı ve açıklamayı göster

Cevap: Withhold the medications, document the client's refusal, and notify the healthcare provider of the client's wishes.

Cevap

Withhold the medications, document the client's refusal, and notify the healthcare provider of the client's wishes.
The correct answer demonstrates advocacy and respect for the principle of autonomy. An alert, oriented, and competent adult has the absolute right to refuse any medical treatment, including life-sustaining medications. The nurse's role is to respect this decision, document it accurately, and inform the interdisciplinary team so the care plan can be adjusted to focus on the client's comfort.

Adım Adım Çözüm

1
Assess the client's cognitive status and capacity to make healthcare decisions.
The client is determined to be alert, oriented, and competent to make autonomous decisions.
Competency must be established to ensure the client has the legal right to refuse care.
2
Identify the primary ethical principle involved in the scenario.
The core principle is autonomy (self-determination).
Nurses must respect the healthcare decisions made by competent clients, even if family members disagree with those decisions.
3
Implement the ethically and legally sound nursing intervention.
The nurse withholds the medication, documents the refusal, and contacts the provider.
This protects the client's rights, prevents battery, and ensures the wider healthcare team is aware of the client's changing goals of care.

Anahtar Kavram

Client Autonomy and Informed Refusal
Soru 2030Soru →

Nurses encounter complex clinical situations that require the precise application of core ethical principles. Match each clinical nursing scenario to the primary ethical principle it most directly demonstrates.

Soldaki öğeye tıklayın, sonra eşleşen sağdaki öğeye tıklayın

Öğeler

Committing to return with an antiemetic in 10 minutes, but delegating the administration to a colleague when unexpectedly pulled into a resuscitation effort.
Refusing a provider's directive to administer a normal saline injection while verbally telling the client it is a potent intravenous analgesic.
Withholding a scheduled dose of a negative chronotropic medication after assessing a client's apical heart rate at 54 beats per minute and noting visual halos.
Allocating limited intensive care beds during a mass casualty incident based strictly on survivability and acuity rather than a client's social prominence.
Supporting a mentally competent adult client with an acute gastrointestinal bleed who chooses to sign out against medical advice for personal reasons.

Eşleşmeler

Cevabı ve açıklamayı göster

Cevap

1 matches Fidelity, 2 matches Veracity, 3 matches Nonmaleficence, 4 matches Justice, and 5 matches Autonomy.
Each scenario illustrates a core ethical principle. Delegating care to meet a promised timeline represents fidelity. Refusing to lie about a placebo represents veracity. Withholding toxic medication represents nonmaleficence. Fair triage based on acuity represents justice. Honoring a competent client's refusal of care represents autonomy.

Adım Adım Çözüm

1
Analyze the first scenario involving the delegated antiemetic administration.
The nurse honors the timeframe promised to the client by ensuring someone else completes the task.
Fidelity requires nurses to be loyal and keep their promises to clients.
2
Evaluate the second scenario involving the saline injection.
The nurse refuses to participate in deceiving the client about the nature of the medication.
Veracity mandates truth-telling and strictly forbids deceiving clients, even if the provider believes a placebo will reduce anxiety.
3
Assess the third scenario involving withholding the medication.
The nurse identifies signs of drug toxicity and stops the administration to prevent further physiological deterioration.
Nonmaleficence is the fundamental duty to 'do no harm' and protect clients from identifiable risks.
4
Examine the fourth scenario concerning triage bed allocation.
The nurse makes decisions based solely on objective medical need rather than external social factors.
Justice dictates that healthcare resources must be distributed fairly and equitably among all populations.
5
Review the final scenario regarding the client leaving against medical advice.
The nurse advocates for the client's decision despite the inherent medical risks of an active bleed.
Autonomy guarantees a competent individual's right to self-determination and the freedom to accept or refuse medical care.

Anahtar Kavram

Ethical Principles in Nursing Practice
Tahmini Süre:2m 0s
Soru 2031Soru →

After receiving the shift report on an orthopedic step-down unit, the nurse evaluates the needs of several clients. Which intervention is safely within the scope of practice to assign to the unlicensed assistive personnel (UAP)?

Cevabı ve açıklamayı göster

Cevap: Applying anti-embolism stockings to a client who is two days postoperative following a total knee arthroplasty.

Cevap

Applying anti-embolism stockings to a client who is two days postoperative following a total knee arthroplasty.
Applying anti-embolism stockings is a standard, routine procedure that has a predictable outcome. Because the client is two days postoperative and their condition is stable, this task safely falls within the UAP's scope of practice without requiring independent nursing judgment.

Adım Adım Çözüm

1
Analyze the task requirements for applying anti-embolism stockings.
It is determined to be a standard, routine, non-invasive procedure with predictable outcomes.
To verify if the intervention structurally fits within the UAP's basic training and scope of practice.
2
Evaluate the clinical stability of the client.
The client is two days postoperative, indicating a stable, predictable condition.
UAPs can safely perform standard tasks only for stable clients whose conditions are not rapidly changing.
3
Apply the core principles of nursing delegation (EAT).
The task does not involve Evaluation, Assessment, or Teaching.
To ensure the decision strictly aligns with the National Council of State Boards of Nursing (NCSBN) delegation guidelines.

Anahtar Kavram

Delegation to Unlicensed Assistive Personnel (UAP)
Soru 2032Soru →

An emergency code is initiated for a client on an inpatient oncology-hematology unit. The primary registered nurse (RN) must urgently transfer the care of three stable clients to a licensed practical nurse (LPN/VN) and an unlicensed assistive personnel (UAP) who have just arrived from the float pool.

Which delegation instruction by the primary RN demonstrates the most accurate application of scope of practice principles?

Cevabı ve açıklamayı göster

Cevap: Directing the LPN/VN to perform routine sterile tracheostomy site care, execute nasotracheal suctioning, and administer scheduled enteral bolus feedings for a client with advanced laryngeal cancer.

Cevap

Directing the LPN/VN to perform routine sterile tracheostomy site care, execute nasotracheal suctioning, and administer scheduled enteral bolus feedings for a client with advanced laryngeal cancer.
The correct answer involves tasks that are standard, routine procedures (sterile tracheostomy care, suctioning, and enteral feedings). Although these tasks appear complex because they involve the airway, they have predictable outcomes and follow established protocols. Therefore, they are safely within the LPN/VN scope of practice for a stable client with a chronic condition.

Adım Adım Çözüm

1
Analyze the client stability and the complexity of the tasks in the correct option.
The client with laryngeal cancer requires tracheostomy care, suctioning, and tube feedings, which are standard procedures on an established airway.
Tasks with predictable outcomes that do not require independent nursing judgment can be safely delegated to an LPN/VN, even if they appear complex.
2
Evaluate the UAP delegation option regarding the biologic infusion.
The UAP is asked to monitor for specific signs of anaphylaxis (throat tightness, flushing) during a high-risk, first-time infusion.
This requires clinical assessment and interpretation of life-threatening symptoms, which falls strictly outside the UAP scope of practice.
3
Evaluate the LPN/VN delegation option regarding pain medication.
The LPN/VN is asked to evaluate the client's response to an intravenous narcotic.
Evaluation of interventions, especially for acute pain and IV medications, is a core component of the RN's nursing process and cannot be delegated.
4
Evaluate the LPN/VN delegation option regarding discharge teaching.
The LPN/VN is asked to conduct a final review of a comprehensive discharge packet.
While LPN/VNs can reinforce previously taught information, conducting final comprehensive discharge teaching and evaluating learning readiness is strictly an RN responsibility.

Anahtar Kavram

The RN cannot delegate tasks that require independent nursing knowledge, comprehensive assessment, clinical judgment, primary teaching, or evaluation. However, LPN/VNs can safely perform complex but standard physiological tasks (like sterile dressing changes, suctioning, and tube feedings) on stable clients with predictable outcomes.
Tahmini Süre:1m 30s
Soru 2033Soru →

A 16-year-old legally emancipated client is rushed to the emergency department with a suspected ruptured ectopic pregnancy. The client is visibly confused, lethargic, and hypotensive with a blood pressure of 72/40 mm Hg. The client repeatedly mumbles, 'Don't touch me... just let me go.' Shortly after, the client's parent arrives, demanding to review the client's pregnancy test results and insisting on signing all treatment consent forms. The unlicensed assistive personnel (UAP) recommends quickly tying the client's hands to the bed rails so the healthcare provider can insert an emergency central venous catheter.

Which of the following nursing actions fulfill the required legal and clinical responsibilities for this client? (Select all that apply)

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Proceed with rapid emergency interventions under the legal principle of implied consent due to the life-threatening condition.; Withhold the pregnancy test results and medical records from the parent to uphold the client's legal privacy rights.; Utilize a staff member to gently hold the client's hand and provide verbal reassurance prior to considering physical restraints.

Cevap

The legally and clinically required actions are to proceed with emergency interventions under implied consent, withhold the medical records from the parent to protect the emancipated minor's privacy, and utilize verbal reassurance before considering physical restraints.
The registered nurse must synthesize multiple legal and clinical principles in this critical scenario. First, the client's confusion and lethargy are late signs of hemorrhagic shock, rendering the client incapacitated. In life-threatening emergencies where an incapacitated client cannot consent, the legal principle of implied consent permits immediate, life-saving treatment. Second, because the client is a legally emancipated minor, they possess full adult rights regarding healthcare decisions and privacy (HIPAA); therefore, the parent has no legal authority to view medical records or provide consent. Finally, despite the emergency nature of the central line placement, the nurse is legally obligated to attempt less restrictive safety measures—such as assigning a staff member to provide verbal redirection and physical presence—before resorting to physical restraints.

Adım Adım Çözüm

1
Evaluate the client's capacity to refuse care and determine the appropriate consent pathway.
The client is in hemorrhagic shock, lacking the cognitive capacity to refuse; therefore, implied consent applies for life-saving emergency treatment.
The emergency doctrine allows healthcare providers to assume a reasonable person would consent to life-saving interventions when they are incapacitated and unable to provide informed consent.
2
Address the parent's demand for medical records and consent authority based on the client's legal status.
The nurse must deny the parent access to the records and the right to consent.
A legally emancipated minor possesses the same healthcare privacy rights (HIPAA) and consent authority as an adult, completely superseding parental rights.
3
Prioritize safety interventions and appropriate task delegation for a confused, critically ill client.
The nurse must attempt non-restrictive safety measures first and personally assess the client's neurological status.
Legal standards dictate using the least restrictive restraint alternatives, and the RN cannot delegate the clinical evaluation of a deteriorating client to a UAP.

Anahtar Kavram

Legal principles of implied consent in life-threatening emergencies, emancipated minor privacy rights, and the mandate for least restrictive safety environments.
Soru 2034Soru →

A nurse on an acute care unit is reviewing the clinical status of multiple assigned clients. Which of the following client situations indicate an acute deterioration requiring immediate intervention? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: A client with a history of asthma who suddenly stops wheezing and exhibits intercostal retractions; A client with a deep vein thrombosis who reports a sudden onset of sharp chest pain and dyspnea

Cevap

The clients requiring immediate intervention are the one with asthma who has a sudden cessation of wheezing (silent chest) and the one with a deep vein thrombosis who develops sudden chest pain and dyspnea (pulmonary embolism).
Clients experiencing acute, sudden physiological deterioration related to airway, breathing, or circulation take the highest priority. The cessation of wheezing with retractions indicates an airway emergency (silent chest). Sudden chest pain and dyspnea in a client with a deep vein thrombosis indicates a pulmonary embolism, which is a severe circulatory and respiratory emergency.

Adım Adım Çözüm

1
Evaluate each client's clinical presentation using the Airway, Breathing, and Circulation (ABC) prioritization framework.
The client with asthma stopping wheezing has an airway/breathing compromise. The client with a deep vein thrombosis experiencing sudden dyspnea has a breathing/circulation compromise.
The ABC framework ensures that acute, life-threatening physiological conditions are addressed before stable or chronic issues.
2
Distinguish between acute, unexpected manifestations and chronic, expected findings among the remaining clients.
The oxygen saturation of 91% in COPD, mild itching under a cast, and ankle edema in heart failure are identified as expected or chronic findings.
Clients with sudden, unexpected instability always take priority over clients experiencing chronic, anticipated disease manifestations.

Anahtar Kavram

Prioritization using the ABC framework and distinguishing acute versus chronic findings.
Soru 2035Soru →

Match each core ethical principle to the clinical scenario that best demonstrates its application in nursing practice.

Soldaki öğeye tıklayın, sonra eşleşen sağdaki öğeye tıklayın

Öğeler

Autonomy
Beneficence
Justice
Fidelity

Eşleşmeler

Cevabı ve açıklamayı göster

Cevap

Autonomy pairs with respecting the refusal of a blood transfusion; Beneficence pairs with administering pain medication; Justice pairs with providing equal care regardless of insurance; Fidelity pairs with returning exactly as promised.
Each clinical scenario directly illustrates one of the foundational ethical principles of nursing. Autonomy focuses on the client's independence in decision-making; Beneficence focuses on taking action to help and do good; Justice focuses on fairness and equality in care delivery; and Fidelity focuses on trust and keeping promises.

Adım Adım Çözüm

1
Analyze the definition of Autonomy.
Matches with the scenario of a client refusing a blood transfusion.
Autonomy requires nurses to respect a client's right to make independent healthcare decisions, even if the nurse disagrees.
2
Analyze the definition of Beneficence.
Matches with the scenario of administering pain medication.
Beneficence means acting in the best interest of the client to promote their well-being and alleviate suffering.
3
Analyze the definition of Justice.
Matches with the scenario of providing equal care regardless of insurance status.
Justice mandates the fair and equitable distribution of care and resources to all individuals.
4
Analyze the definition of Fidelity.
Matches with the scenario of returning in 30 minutes as promised.
Fidelity requires nurses to be loyal, truthful, and to follow through on commitments made to clients.

Anahtar Kavram

Core Ethical Principles in Nursing
Soru 2036Soru →

A client is in the preoperative unit awaiting an elective percutaneous transluminal coronary angioplasty (PTCA). The client has not received any premedication. As the nurse prepares to witness the informed consent signature, the client states, 'I am not sure I want to go through with this if there is a risk I could have a heart attack during the procedure.' Arrange the following nursing actions in the correct chronological sequence.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence is to instruct the client not to sign, assess their specific concerns, contact the cardiologist, witness the signature after clarification, and finally document the event.
When a client expresses doubts or a lack of understanding about a procedure, the nurse must act as an advocate. The immediate priority is to stop the consent process to prevent an invalid signature. Next, the nurse assesses the client to understand exactly what needs clarification. The nurse then contacts the healthcare provider, as it is the provider's legal duty to explain risks and benefits. Once the provider has answered the client's questions and the client is ready, the nurse witnesses the signature. Finally, comprehensive documentation of the delay, the provider's intervention, and the completed consent is entered into the medical record.

Adım Adım Çözüm

1
Instruct the client not to sign the consent form.
Prevents the execution of an invalid informed consent.
A client must be fully informed and clear about risks before signing; halting the process protects the client's legal rights.
2
Ask the client to elaborate on their specific concerns.
Identifies the exact nature of the client's knowledge deficit.
The nurse needs clear information to accurately communicate the client's needs to the healthcare provider.
3
Contact the cardiologist to return and provide further clarification.
Transfers the responsibility of explaining procedural risks back to the provider.
It is outside the registered nurse's scope of practice to explain the primary risks and alternatives of a medical procedure.
4
Witness the client's signature once concerns are addressed.
Finalizes the informed consent process legally.
The nurse's role is to verify that the signature is voluntary, authentic, and obtained while the client is competent and informed.
5
Document the entire event in the medical record.
Creates a permanent legal and medical record of the interaction.
Accurate documentation of client care, including advocacy and provider notification, is a standard of nursing practice.

Anahtar Kavram

Informed Consent and Nurse Advocacy
Soru 2037Soru →

After receiving the handoff report on a cardiovascular step-down unit, the registered nurse must determine the order of initial client rounds. Which client necessitates the nurse's immediate attention?

Cevabı ve açıklamayı göster

Cevap: A 55-year-old client admitted for a hypertensive crisis who suddenly reports a tearing sensation in the upper back and demonstrates a 35 mm Hg systolic blood pressure discrepancy between arms.

Cevap

The client admitted for a hypertensive crisis who is experiencing new tearing back pain and a blood pressure discrepancy between arms is the highest priority.
The client experiencing sudden tearing back pain and a significant systolic blood pressure variance between arms is exhibiting classic symptoms of an acute aortic dissection. This is an immediate, catastrophic circulatory emergency that poses a direct threat to life and requires rapid assessment, blood pressure control, and potential surgical intervention.

Adım Adım Çözüm

1
Analyze the clinical presentation of the client with tearing back pain and blood pressure discrepancy.
Identified as a suspected acute aortic dissection, a rapidly fatal vascular emergency requiring immediate medical and surgical intervention.
Airway, Breathing, and Circulation (ABC) frameworks prioritize active circulatory collapse or catastrophic bleeding risks.
2
Evaluate the client with a prolonged aPTT of 120 seconds.
Recognized as a high-risk medication situation requiring intervention, but lacking active physiological instability or current hemorrhage.
Asymptomatic laboratory abnormalities are prioritized below active, lethal physiological manifestations.
3
Assess the clients with COPD and heart failure.
Identified their findings (PaCO2 55 mm Hg, SpO2 89%, BNP 850 pg/mL, pedal edema) as expected, chronic baselines for their respective disease processes.
Expected or chronic findings are the lowest priority in triage situations.
4
Compare all clients to determine the most urgent need.
The client with the suspected aortic dissection requires the most immediate life-saving assessment.
Acute, unexpected, and life-threatening conditions supersede chronic, expected conditions and asymptomatic lab abnormalities.

Anahtar Kavram

Prioritization requires distinguishing between acute, life-threatening emergencies (e.g., aortic dissection) and urgent but asymptomatic abnormal laboratory values or expected chronic manifestations.
Tahmini Süre:1m 15s
Soru 2038Soru →

A client arrives at the emergency department triage area displaying severe dyspnea, a temperature of 102.4°F (39.1°C), and a blood pressure of 86/48 mm Hg. The provider prescribes several immediate interventions for suspected sepsis. In what sequence should the nurse perform the following actions? Arrange the actions in the order they should be implemented, from first to last.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence is to first administer oxygen, followed by establishing intravenous access, then obtaining blood cultures, and finally infusing the broad-spectrum antibiotic.
The correct sequence adheres strictly to the Airway, Breathing, Circulation (ABC) framework and evidence-based sepsis protocols. Supporting breathing with oxygen is the absolute first step. Next, establishing circulation via intravenous access allows for subsequent treatments. Finally, drawing blood cultures must precede the administration of broad-spectrum antibiotics to ensure accurate pathogen identification.

Adım Adım Çözüm

1
Evaluate the client's physiological needs using the Airway, Breathing, Circulation (ABC) framework.
Dyspnea is identified as a Breathing issue, which takes precedence over Circulation issues.
The ABC framework dictates that oxygenation and ventilation are the highest priorities to sustain life.
2
Address the next highest priority according to the ABC framework.
Intravenous access is established to support Circulation.
The client is hypotensive and requires circulatory support and medication administration.
3
Determine the correct pharmacological sequence for a client with suspected sepsis.
Blood cultures are drawn prior to antibiotic administration.
Administering antibiotics before drawing blood cultures can inhibit bacterial growth in the sample, leading to false-negative results and inappropriate long-term antibiotic therapy.

Anahtar Kavram

Prioritization using the ABC framework and the standard sequence of sepsis interventions (cultures before antibiotics).
Soru 2039Soru →

A nurse is providing an interdepartmental handoff report to a home health nurse using the SBAR (Situation, Background, Assessment, Recommendation) format. The client is being discharged after a severe ischemic stroke that resulted in right-sided hemiplegia. During the assessment phase, the discharging nurse notes that the client's spouse is highly anxious and feels overwhelmed about managing the client's daily hygiene, dressing, and feeding. Which statement by the discharging nurse represents the most appropriate "Recommendation" to ensure safe, interdisciplinary care?

Cevabı ve açıklamayı göster

Cevap: I recommend coordinating with an occupational therapist to evaluate the client and teach the spouse adaptive techniques for activities of daily living.

Cevap

The most appropriate recommendation is to coordinate with an occupational therapist to evaluate the client and teach the spouse adaptive techniques for activities of daily living.
The correct answer accurately identifies the occupational therapist as the appropriate interdisciplinary team member to address deficits in activities of daily living (ADLs) and fine motor skills. Suggesting this referral in the 'Recommendation' phase of SBAR directly addresses the spouse's concerns and ensures safe, effective care planning for the transition home.

Adım Adım Çözüm

1
Analyze the client's clinical deficits and the spouse's identified needs.
The client has right-sided hemiplegia, and the spouse is anxious about managing activities of daily living (ADLs) such as hygiene, dressing, and feeding.
Identifying the specific functional deficits is essential for determining which interdisciplinary team member possesses the correct scope of practice to assist.
2
Apply the principles of interdisciplinary collaboration and the SBAR communication format.
The 'Recommendation' phase of SBAR should propose an actionable, safe, and scope-appropriate intervention. Occupational therapy is the specific discipline trained to address fine motor skills and ADLs.
Appropriate interdisciplinary collaboration ensures the client receives specialized care, maximizing independence and ensuring a safe transition to the home environment.

Anahtar Kavram

Occupational therapists are the interdisciplinary team members who specialize in evaluating and teaching clients and families adaptive techniques for fine motor skills and activities of daily living (ADLs).
Soru 2040Soru →

While performing an assessment in an urgent care center, a nurse evaluates a preschool-aged child with a spiral fracture of the humerus. The accompanying parent states the child simply tripped over a small toy. The injury pattern is highly inconsistent with the provided history. What is the nurse's immediate legal responsibility in this situation?

Cevabı ve açıklamayı göster

Cevap: Notify the designated child protective services agency about the suspected abuse.

Cevap

The nurse must notify the designated child protective services agency about the suspected abuse.
Registered nurses are legally mandated reporters. When a child presents with injuries that are highly inconsistent with the provided history, such as a spiral fracture resulting from a reported simple fall, the nurse has a strict legal obligation to report the suspected abuse immediately to child protective services or designated authorities. The nurse only needs reasonable suspicion, not definitive proof, to make this report.

Adım Adım Çözüm

1
Identify the incongruence between the child's physical injury and the caregiver's explanation.
The nurse suspects potential physical abuse based on the clinical presentation of a spiral fracture, which typically results from a twisting force rather than a simple fall.
Recognizing red flags for abuse is the first step in protecting vulnerable populations.
2
Determine the legally mandated nursing action for suspected child abuse.
The nurse recognizes the legal obligation to report the suspicion immediately to the designated authorities.
Nurses are designated as mandatory reporters by law and must act on reasonable suspicion without waiting for definitive proof.

Anahtar Kavram

Mandatory Reporting Responsibilities
ÖncekiSayfa 102 / 195Sonraki
Tüm alıştırma soruları — NCLEX-RN | Examkin