Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is obtaining informed consent from a client who is scheduled for an invasive procedure. The client states, "I don't understand why this procedure is necessary." Which of the following actions should the nurse take?
A. Ask the client to sign the consent form anyway.
This would violate the patient's right to autonomy and self-determination
B. Notify the charge nurse about the situation.
Informed consent is when a healthcare provider explains a medical treatment to a patient before the patient agrees to it. The patient has the right to know their state of health, the diagnosis, and the treatments available, and to choose any alternative. The nurse is responsible for obtaining consent when initiating care, and reviewing consent before providing the care ordered by another health care professional. If the patient does not understand why the procedure is necessary, the nurse should notify the charge nurse or the physician who ordered the procedure, so that they can provide more information and answer any questions
C. Remind the client about the specifics of the procedure.
These are not within the nurse's scope of practice and may be considered as giving medical advice.
D. Explain to the client that the procedure will help treat his diagnosis
These are not within the nurse's scope of practice and may be considered as giving medical advice.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Comprehensive Predictor 2023 Proctored Exam. Take the full exam now
Full Explanation
The correct answer is B. Notify the charge nurse about the situation. Informed consent is when a healthcare provider explains a medical treatment to a patient before the patient agrees to it. The patient has the right to know their state of health, the diagnosis, and the treatments available, and to choose any alternative. The nurse is responsible for obtaining consent when initiating care, and reviewing consent before providing the care ordered by another health care professional. If the patient does not understand why the procedure is necessary, the nurse should notify the charge nurse or the physician who ordered the procedure, so that they can provide more information and answer any questions.
The nurse should not ask the client to sign the consent form anyway (A), as this would violate the patient's right to autonomy and self-determination.
The nurse should not remind the client about the specifics of the procedure (C) or explain to the client that the procedure will help treat his diagnosis (D), as these are not within the nurse's scope of practice and may be considered as giving medical advice.
Similar Questions
A nurse is collecting data from a 4-month-old infant at a well-child visit. For which of the following findings should the nurse notify the provider?
A. Anterior fontanel closed
Anterior fontanel closed. The anterior fontanel is one of two soft spots on an infant's skull that allow for brain growth and development. The anterior fontanel normally closes between 9 and 18 months of age. If it closes earlier than expected, it may indicate a condition called craniosynostosis, which is when the skull bones fuse prematurely and restrict brain growth. This can lead to increased intracranial pressure, developmental delays, and abnormal head shape. Therefore, if a nurse observes that a 4-month-old infant has a closed anterior fontanel, they should notify the provider for further evaluation. The other options are normal developmental milestones for a 4-month-old infant and do not require notification of the provider.
B. Plays with toes
C. Posterior fontanel closed
D. Moves objects to mouth
Full Explanation
The correct answer is A. Anterior fontanel closed. The anterior fontanel is one of two soft spots on an infant's skull that allow for brain growth and development. The anterior fontanel normally closes between 9 and 18 months of age. If it closes earlier than expected, it may indicate a condition called craniosynostosis, which is when the skull bones fuse prematurely and restrict brain growth. This can lead to increased intracranial pressure, developmental delays, and abnormal head shape. Therefore, if a nurse observes that a 4-month-old infant has a closed anterior fontanel, they should notify the provider for further evaluation. The other options are normal developmental milestones for a 4-month-old
infant and do not require notification of the provider.
A nurse is caring for a client who follows a kosher diet. Which of the following menu items should the nurse include on the tray?
A. Shrimp salad
B. Pulled-pork sandwich
C. Clam chowder
D. Roasted salmon
A kosher diet is based on Jewish dietary laws that prohibit certain foods and combinations of foods. Some of these rules include avoiding pork, shellfish, and mixing meat and dairy products. Therefore, shrimp salad pulled pork sandwich, and clam chowder are all non-kosher menu items that should be avoided by a client who follows a kosher diet. Roasted salmon is a kosher menu item that can be included on the tray, as long as it is not served with any dairy products or non-kosher ingredients.
Full Explanation
The correct answer is D. Roasted salmon. A kosher diet is based on Jewish dietary laws that prohibit certain foods and combinations of foods. Some of these rules include avoiding pork, and shellfish, and mixing meat and dairy products. Therefore, shrimp salad, pulled pork sandwich, and clam chowder are all non-kosher menu items that should be avoided by a
client who follows a kosher diet. Roasted salmon is a kosher menu item that can be included on the tray, as long as it is not served with any dairy products or non-kosher ingredients.
A nurse is collecting data from a child who has pertussis. Which of the following manifestations should the nurse expect?
A. Beefy, red tongue
B. Productive cough with thick mucus
Pertussis, also known as whooping cough, is a highly contagious respiratory infection caused by Bordetella pertussis bacteria. It causes severe coughing spells that can interfere with breathing and produce a characteristic whooping sound when inhaling. The cough may also be accompanied by thick mucus that can be difficult to clear. Therefore, a nurse should expect to see a productive cough with thick mucus as a manifestation of pertussis in a child. The other options are not typical manifestations of pertussis, but rather of other conditions. A beefy, red tongue may indicate vitamin B12 deficiency or pernicious anemia. Facial erythema may indicate fever, allergy, or inflammation. Peeling of the hands and feet may indicate Kawasaki disease, a rare inflammatory disorder that affects the blood vessels.
C. Facial erythema
D. Peeling of the hands and feet
Full Explanation
The correct answer is B. Productive cough with thick mucus. Pertussis, also known as whooping cough, is a highly contagious respiratory infection caused by Bordetella pertussis bacteria. It causes severe coughing spells that can interfere with breathing and produce a characteristic whooping sound when inhaling. The cough may also be accompanied by thick mucus that can be difficult to clear. Therefore, a nurse should expect to see a productive cough with thick mucus as a manifestation of pertussis in a child. The other options are not typical manifestations of pertussis, but rather of other conditions. A beefy, red tongue may indicate vitamin B12 deficiency or pernicious anemia. Facial erythema may indicate fever, allergy, or inflammation. Peeling of the hands and feet may indicate Kawasaki disease, a rare inflammatory disorder that affects the blood vessels.