Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse in the emergency department is preparing to care for a client who arrived via ambulance. The client is disoriented and has a cardiac arrhythmia. Which of the following actions should the nurse take?
A. Notify risk management before initiating treatment.
Notifying risk management before initiating treatment is not necessary in this emergent situation; patient care should take precedence.
B. Proceed with treatment without obtaining written consent.
In emergent situations where a patient lacks decision-making capacity and requiresimmediate treatment to prevent harm, consent for treatment can be assumed based on the principle of implied consent.
C. Contact the client's next of kin to obtain consent for treatment.
Contacting the client's next of kin for consent might delay necessary treatment for the disoriented and arrhythmic client, which could be harmful.
D. Have the client sign a consent for treatment.
Having the client sign a consent for treatment might not be feasible or appropriate if the client is disoriented and lacks decision-making capacity in an emergency situation.
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Full Explanation
A. Notifying risk management before initiating treatment is not necessary in this emergent situation; patient care should take precedence.
B. In emergent situations where a patient lacks decision-making capacity and requires
immediate treatment to prevent harm, consent for treatment can be assumed based on the principle of implied consent.
C. Contacting the client's next of kin for consent might delay necessary treatment for the disoriented and arrhythmic client, which could be harmful.
D. Having the client sign a consent for treatment might not be feasible or appropriate if the client is disoriented and lacks decision-making capacity in an emergency situation.
Similar Questions
A nurse on a medical-surgical unit is caring for a client who asks about advance directives and states that he wants to appoint a health care proxy. Which of the following responses should the nurse make?
A. "You must choose a member of your family to serve as your health care proxy."
It's not mandatory for a health care proxy to be a member of the client's family; the most important aspect is appointing someone the client trusts to make decisions on their behalf.
B. "A health care proxy can make decisions for you when you are unable to do so."
A health care proxy is someone designated by the client to make medical decisions when the client is unable to do so, based on the client's preferences and wishes.
C. "You should appoint a health care proxy before undergoing an invasive procedure."
While it's advisable to have an advance directive in place before procedures or when facing serious illnesses, the timing of appointing a health care proxy should not be confined to only these situations.
D. "It is necessary for an attorney to approve your health care proxy."
It is not necessary for an attorney to approve the appointment of a health care proxy; the client can designate someone they trust without legal counsel's approval.
Full Explanation
A. It's not mandatory for a health care proxy to be a member of the client's family; the most important aspect is appointing someone the client trusts to make decisions on their behalf.
B. A health care proxy is someone designated by the client to make medical decisions when the client is unable to do so, based on the client's preferences and wishes.
C. While it's advisable to have an advance directive in place before procedures or when facing serious illnesses, the timing of appointing a health care proxy should not be confined to only these situations.
D. It is not necessary for an attorney to approve the appointment of a health care proxy; the client can designate someone they trust without legal counsel's approval.
A charge nurse making rounds observes that an assistive personnel (AP) has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first?
A. Inform the unit manager of the incident.
Informing the unit manager is essential but not the first immediate action when a client is improperly restrained.
B. Speak with the AP about the incident.
Speaking with the AP about the incident is important, but the priority is to ensure the client's safety and well-being.
C. Remove the restraints from the client's wrists.
Removing the restraints from the client's wrists is the first action to address theinappropriate application of restraints without a prescription to ensure the client's safety and prevent harm.
D. Review the chart for nonrestraint alternatives for agitation,
Reviewing the chart for nonrestraint alternatives for agitation is important, but the priority is to address the immediate issue of the improperly applied restraints to the client.
Full Explanation
A. Informing the unit manager is essential but not the first immediate action when a client is improperly restrained.
B. Speaking with the AP about the incident is important, but the priority is to ensure the client's safety and well-being.
C. Removing the restraints from the client's wrists is the first action to address the
inappropriate application of restraints without a prescription to ensure the client's safety and prevent harm.
D. Reviewing the chart for nonrestraint alternatives for agitation is important, but the priority is to address the immediate issue of the improperly applied restraints to the client.
A charge nurse on an obstetrical unit is preparing the shift assignment. Which of the following clients should be assigned to an RN who has floated from a medical-surgical unit?
A. A client who has gestational diabetes and is receiving biweekly nonstress tests
A client with gestational diabetes receiving biweekly nonstress tests typically requires monitoring and assessment that align more closely with obstetric nursing knowledge and skills rather than medical-surgical nursing.
B. A multigravida client who has preeclampsia and is receiving misoprostol for induction of labor
A multigravida client with preeclampsia receiving misoprostol for induction of labor needs specialized obstetric care due to the complexity of the condition and the induction process.
C. A client who is at 32 weeks of gestation and has premature rupture of membranes
A client at 32 weeks of gestation with premature rupture of membranes would require obstetric care expertise for monitoring and management.
D. A primigravida client who is 1 day postoperative following a Cesarean section and has a PCA pump
A primigravida client 1 day postoperative following a Cesarean section with a patient- controlled analgesia (PCA) pump requires specialized postoperative obstetric care,making this assignment suitable for the RN who floated from a medical-surgical unit due to their experience with postoperative care and pain management.
Full Explanation
A. A client with gestational diabetes receiving biweekly nonstress tests typically requires monitoring and assessment that align more closely with obstetric nursing knowledge and skills rather than medical-surgical nursing.
B. A multigravida client with preeclampsia receiving misoprostol for induction of labor needs specialized obstetric care due to the complexity of the condition and the induction process.
C. A client at 32 weeks of gestation with premature rupture of membranes would require obstetric care expertise for monitoring and management.
D. A primigravida client 1 day postoperative following a Cesarean section with a patient- controlled analgesia (PCA) pump requires specialized postoperative obstetric care,
making this assignment suitable for the RN who floated from a medical-surgical unit due to their experience with postoperative care and pain management.