Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse in an emergency department is caring for a client who is unconscious and requires emergency medical procedures. The nurse is unable to locate members of the client's family to obtain consent. Which of the following actions should the nurse take?
A. Contact the facility's ethics committee
This is incorrect because it is not an urgent action and it does not address the client's immediate needs. The ethics committee can be consulted later if there are ethical dilemmas or conflicts regarding the client's care.
B. Obtain consent from the client's employer
This is incorrect because it is not a valid source of consent. The employer has no legal or ethical authority to make decisions for the client, unless they are also a designated surrogate or proxy.
C. Limit care to comfort measures
This is incorrect because it does not meet the standard of care for an emergency situation. The nurse has a duty to provide life-saving interventions for a client who is unconscious and requires emergency medical procedures, unless there is evidence of a valid advance directive that states otherwise.
D. Proceed with provision of medical care
This is correct because it follows the principle of implied consent, which assumes that a reasonable person would consent to emergency treatment if they were able to do so. The nurse should document the circumstances and continue to search for family members or other sources of consent.
This question is an excerpt from Nurse Dive's nursing test bank - RN Comprehensive Online Practice 2019 B with NGN Proctored Exam. Take the full exam now
Full Explanation
Proceed with provision of medical care.
- A. Contact the facility's ethics committee: This is incorrect because it is not an urgent action and it does not address the client's immediate needs. The ethics committee can be consulted later if there are ethical dilemmas or conflicts regarding the client's care.
- B. Obtain consent from the client's employer: This is incorrect because it is not a valid source of consent. The employer has no legal or ethical authority to make decisions for the client, unless they are also a designated surrogate or proxy.
- C. Limit care to comfort measures: This is incorrect because it does not meet the standard of care for an emergency situation. The nurse has a duty to provide life-saving interventions for a client who is unconscious and requires emergency medical procedures, unless there is evidence of a valid advance directive that states otherwise.
- D. Proceed with provision of medical care: This is correct because it follows the principle of implied consent, which assumes that a reasonable person would consent to emergency treatment if they were able to do so. The nurse should document the circumstances and continue to search for family members or other sources of consent.
Similar Questions
A charge nurse is speaking with the partner of a client. The partner states that the client is not receiving adequate care. Which of the following actions should the charge nurse take first to resolve the situation?
A. Evaluate the changes the partner requests
This is incorrect because it is not the first action to take. The charge nurse should first listen to and acknowledge the partner's complaints before evaluating any changes or solutions.
B. Review the client's plan of care
This is incorrect because it is not the first action to take. The charge nurse should first understand what aspects of care are unsatisfactory for the partner and why they feel that way.
C. Analyze other reports of poor care to look for trends
This is incorrect because it is not relevant to this situation. The charge nurse should focus on addressing this specific case of dissatisfaction rather than looking for general patterns or issues.
D. Ask the partner to list specific concerns
This is correct because it shows respect and empathy for the partner and allows for clarification and communication of their expectations and needs. It also helps identify any gaps or misunderstandings in the client's care and facilitates problem-solving and resolution.
Full Explanation
Ask the partner to list specific concerns.
- A. Evaluate the changes the partner requests: This is incorrect because it is not the first action to take. The charge nurse should first listen to and acknowledge the partner's complaints before evaluating any changes or solutions.
- B. Review the client's plan of care: This is incorrect because it is not the first action to take. The charge nurse should first understand what aspects of care are unsatisfactory for the partner and why they feel that way.
- C. Analyze other reports of poor care to look for trends: This is incorrect because it is not relevant to this situation. The charge nurse should focus on addressing this specific case of dissatisfaction rather than looking for general patterns or issues.
- D. Ask the partner to list specific concerns: This is correct because it shows respect and empathy for the partner and allows for clarification and communication of their expectations and needs. It also helps identify any gaps or misunderstandings in the client's care and facilitates problem-solving and resolution.
A nurse administers an incorrect dose of medication to a client. The nurse recognizes the error immediately and completes an incident report. Which of the following facts related to the incident should the nurse document in the client's medical record?
A. Completion of the incident report
The completion of the incident report should not be documented in the client's medical record, but in a separate file for quality improvement purposes.
B. Time the medication was given
The time the medication was given is an essential fact related to the incident that should be documented in the client's medical record.
C. Reason for the medication error
The reason for the medication error should not be documented in the client's medical record, but in the incident report for analysis and prevention of future errors.
D. Notification of the pharmacist
The notification of the pharmacist should not be documented in the client's medical record, but in the incident report for follow-up and corrective actions.
Full Explanation
A is incorrect because the completion of the incident report should not be documented in the client's medical record, but in a separate file for quality improvement purposes.
B is correct because the time the medication was given is an essential fact related to the incident that should be documented in the client's medical record.
C is incorrect because the reason for the medication error should not be documented in the client's medical record, but in the incident report for analysis and prevention of future errors.
D is incorrect because the notification of the pharmacist should not be documented in the client's medical record, but in the incident report for follow-up and corrective actions.
A nurse is planning care for a client who has rheumatoid arthritis and has moderate to severe pain in multiple joints. Which of the following actions should the nurse plan to take?
A. Perform ADLs for the client to promote rest
This is incorrect because performing ADLs for the client can increase their dependence and decrease their self-esteem. The nurse should encourage the client to perform ADLs as much as possible, with assistance as needed, to maintain their function and mobility.
B. Allow for frequent rest periods throughout the day
This is correct because rest periods can help reduce fatigue and pain, as well as prevent joint damage and inflammation. The nurse should balance rest and activity for the client and avoid overexertion.
C. Use heat to reduce joint inflammation
This is incorrect because heat can increase inflammation and pain in acute rheumatoid arthritis. The nurse should use cold applications to reduce swelling and inflammation in acute episodes, and use heat for chronic stiffness and pain.
D. Develop a daily schedule for acetaminophen up to 6 g/day that covers peak periods of pain
This is incorrect because acetaminophen has a maximum daily dose of 4 g/day, and exceeding this dose can cause liver toxicity. The nurse should monitor the client's liver function and use other analgesics as prescribed.
Full Explanation
Allow for frequent rest periods throughout the day.
- A. Perform ADLs for the client to promote rest. This is incorrect because performing ADLs for the client can increase their dependence and decrease their self-esteem. The nurse should encourage the client to perform ADLs as much as possible, with assistance as needed, to maintain their function and mobility.
- B. Allow for frequent rest periods throughout the day. This is correct because rest periods can help reduce fatigue and pain, as well as prevent joint damage and inflammation. The nurse should balance rest and activity for the client and avoid overexertion.
- C. Use heat to reduce joint inflammation. This is incorrect because heat can increase inflammation and pain in acute rheumatoid arthritis. The nurse should use cold applications to reduce swelling and inflammation in acute episodes, and use heat for chronic stiffness and pain. - D. Develop a daily schedule for acetaminophen up to 6 g/day that covers peak periods of pain. This is incorrect because acetaminophen has a maximum daily dose of 4 g/day, and exceeding this dose can cause liver toxicity. The nurse should monitor the client's liver function and use other analgesics as prescribed.