Tüm alıştırma soruları

After completing initial safety checks on a surgical step-down unit, the registered nurse reviews the latest clinical data for four assigned clients. Which client requires immediate evaluation?

During a routine home care visit, a registered nurse is assessing a senior client who resides with a family caregiver. The client's cognitive function is fully intact. Upon physical examination, the nurse discovers severe dehydration, soiled clothing, and deep bruising along the client's back and arms. While the caregiver is momentarily out of the room, the client whispers, "I know how this looks, but you cannot tell the authorities. I would rather endure this than be locked away in a nursing home." Which of the following describes the most ethically and legally appropriate course of action for the nurse?

A nurse is preparing a client for an elective colonoscopy. The client states, 'The physician told me I need this procedure, but I do not really understand what the risks are.' Which action should the nurse take?

An older adult client with a history of vascular dementia is hospitalized for the treatment of a severe urinary tract infection. The client becomes highly agitated, frequently picking at their peripheral intravenous (IV) catheter, and attempting to climb out of bed unassisted. The client's legally appointed healthcare proxy is currently sitting at the bedside. Which initial nursing action is most legally sound to protect the client's right to a least restrictive environment?

A 78-year-old client is scheduled for an elective surgical procedure. The provider has thoroughly explained the risks, benefits, and alternatives, and the client has signed the consent document. The client's adult child tells the nurse, 'My parent should not be signing legal documents. Lately, they forget where they put their keys and repeat the same stories. Their mind is obviously failing.' The nurse's assessment reveals the client is fully oriented, calmly articulates the purpose of the surgery, and demonstrates a clear understanding of the procedure. Which of the following actions is the most appropriate for the nurse to take?

An older adult client with baseline dementia is admitted for sepsis and becomes acutely agitated, repeatedly attempting to remove their intravenous (IV) catheter. The client's adult child, who holds a verified Durable Power of Attorney for Healthcare (DPOA-HC), tells the nurse, 'I am the legal proxy. I give you permission to put wrist restraints on my parent right now so the IV stays in.' The nurse has not yet triaged the cause of the agitation or attempted other safety measures. Which of the following is the most legally and ethically appropriate action by the nurse?

A nursing team is planning care assignments on a general medical unit for a group of stable clients. The staff mix consists of a registered nurse and one unlicensed assistive personnel (UAP). Which of the following client care activities are appropriate to assign to the UAP? Select all that apply.

During a mid-day interdisciplinary round on a general medical floor, a registered nurse receives updated orders for several assigned clients. The nursing team consists of the registered nurse, a licensed practical nurse, and an unlicensed assistive personnel. Which task delegation represents the safest and most appropriate use of team resources?

A nurse is coordinating the care plan for a client who is recovering from a stroke. The client exhibits weakness in the right leg, struggles to hold a toothbrush, and frequently coughs when drinking water. Which of the following interdisciplinary team members should the nurse include in the collaborative care plan to address these specific needs? Select all that apply.

The charge nurse on a high-acuity progressive care unit is coordinating shift assignments. The nursing team consists of a registered nurse (RN), a licensed practical/vocational nurse (LPN/VN), and an unlicensed assistive personnel (UAP). Which task delegation demonstrates the safest and most appropriate application of delegation principles?

A preoperative unit nurse enters a client's room to complete the final surgical checklist for a scheduled parathyroidectomy. The operating provider just left the room after discussing the procedure. The client is crying and states, "I really do not want my neck cut open, but the doctor insisted that my airway will collapse by tomorrow if I refuse." Which action must the nurse prioritize?

A nurse is reviewing the electronic health records and morning assessment data for a group of assigned clients on a medical-surgical unit. Which of the following client findings indicate a potential life-threatening complication and require the nurse's immediate attention? Select all that apply.

The surgical team is preparing to insert a central venous catheter for a client on the telemetry unit. The primary healthcare provider has just completed discussing the procedure and left the room. When acting as a witness for the informed consent document, which responsibilities belong to the registered nurse? (Select all that apply.)

A client who was recently diagnosed with end-stage renal disease is crying and states, "I do not know how I will ever afford my dialysis treatments." Which action by the nurse represents the most appropriate interdisciplinary collaboration?

A nurse is evaluating a 3-year-old child admitted to the pediatric unit with viral gastroenteritis. Which of the following assessment findings are a priority and require immediate intervention? Select all that apply.

A 72-year-old client is scheduled for an elective cardiac catheterization. The client signed the informed consent document earlier in the day after a comprehensive discussion with the cardiologist. The registered nurse (RN) administers the prescribed preoperative sedation consisting of intravenous midazolam and fentanyl. Fifteen minutes later, while visibly drowsy but easily arousable, the client states, "I have changed my mind. I do not want them to put any wires in my heart. Cancel the procedure." Which is the priority legal and professional action by the RN?

A 68-year-old client with bipolar I disorder is admitted involuntarily to the inpatient psychiatric unit during an acute manic episode. The client's medical record includes a legally valid advance directive designating their adult child as the durable power of attorney for healthcare (DPOA-HC). Currently, the client is pacing the unit rapidly, highly distractible, and displaying pressured speech, but is not exhibiting any threatening or violent behavior. The client abruptly refuses their scheduled oral antipsychotic medication. The adult child calls the unit, insists the nurse administer the medication by any means necessary, and requests a detailed update on the client's condition. The client explicitly states to the nurse, "I forbid you from talking to my child."

Which of the following actions by the registered nurse are legally appropriate? (Select all that apply)

A nurse is preparing to witness an informed consent signature for a client scheduled for an elective appendectomy. The client states, 'The doctor talked to me earlier, but I still do not understand what the risks are.' Arrange the following nursing actions in the correct chronological order. (Place the first action at the top and the last action at the bottom.)

An emergency department nurse is preparing to transfer a stabilized client to an inpatient medical floor while simultaneously managing several new acute admissions. To optimize time and maintain client safety, the nurse enlists the assistance of an unlicensed assistive personnel (UAP). Which specific action should the nurse delegate to the UAP?

A client on a psychiatric unit is scheduled for electroconvulsive therapy (ECT). As the nurse presents the informed consent document, the client asks, "What are the other treatment options if I decide not to do this?" Which of the following is the most appropriate action by the nurse?