Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is delegating care for a group of clients. Which of the following clients should the nurse assign to a licensed practical nurse?
A. A newly admitted client who has diabetes mellitus and requires initial teaching on self- administration of insulin
Teaching a client about self-administration of insulin requires a more advanced level of nursing knowledge and is within the scope of practice for a licensed practical nurse (LPN) or a registered nurse (RN).
B. A client who is scheduled for an endoscopy later today and requires an enema
Administering an enema requires assessment skills and the ability to monitor the client's response, typically within the scope of an RN.
C. A newly admitted client who has sickle cell anemia and requires the development of an initial plan of care
Developing an initial plan of care for a client with sickle cell anemia requires a comprehensive understanding of the condition and its management, which typically falls within the scope of an RN.
D. A client who had a myocardial infarction and will be transferring to the unit from the CCU.
A client transferring from the Critical Care Unit (CCU) after a myocardial infarction would likely need closer monitoring and assessment, tasks generally within the RN's scope of practice.
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Full Explanation
- A: This client requires initial teaching, which is typically the responsibility of a registered nurse due to the educational aspect and the need to assess the client's understanding.
- B: Administering an enema is a task that falls within the scope of practice for a licensed practical nurse and does not require the advanced assessment skills of a registered nurse.
- C: Developing an initial plan of care involves comprehensive assessment and critical thinking, which are responsibilities of a registered nurse.
- D: A client transferring from the CCU after a myocardial infarction would require close monitoring and assessment, which are beyond the scope of practice for a licensed practical nurse.
Similar Questions
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.
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.
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.