Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is preparing to obtain consent from a client who has a tibia fracture. The client received IV morphine sulfate prior to arrival on the unit and is scheduled for surgery. Which of the following actions should the nurse take?
A. Obtain consent from the client.
Option A may not be appropriate if the client is not able to give informed consent.
B. Acknowledge the client and sign the consent.
Option B is not appropriate as it is not within the nurse's scope of practice to sign consent on behalf of a client.
C. Obtain consent from a relative of the client.
When a client is under the influence of opioids and lacks decision-making capacity, consent must be obtained from a legally authorized representative, such as a relative or healthcare proxy. Morphine alters consciousness and impairs executive function, making the client temporarily incompetent. Legal surrogates are empowered to make healthcare decisions in such cases. This ensures ethical compliance and protects patient rights. The nurse must verify documentation of proxy authority before proceeding with consent.
D. Delay the procedure.
Delaying the procedure may be necessary if no authorized proxy is available, but it is not the first action. The priority is to identify and contact a legally authorized representative to obtain valid consent. Delays can compromise care, especially in urgent surgical cases. The nurse must act promptly to secure proxy consent, ensuring procedural integrity and patient safety. Only if no proxy is reachable should delay be considered, with documentation of rationale.
This question is an excerpt from Nurse Dive's nursing test bank - ATI PN Medical Surgical Leadership Proctored Exam. Take the full exam now
Full Explanation
The correct answer is Choice C.
Choice A rationale: Obtaining consent directly from a client who has received IV morphine sulfate is invalid due to impaired cognitive function. Morphine acts on mu-opioid receptors in the central nervous system, reducing alertness, memory retention, and decision-making capacity. Informed consent requires full comprehension of risks, benefits, and alternatives. Morphine’s sedative effects compromise this standard. Normal Glasgow Coma Scale should be 15 for full alertness; sedation lowers this, rendering consent legally and ethically unsound.
Choice B rationale: The nurse cannot legally sign the consent on behalf of the client, even if the client is acknowledged. This violates the principle of autonomy and informed decision-making. The nurse’s role is to witness the client’s signature, not substitute it. Morphine impairs cognition, and any consent obtained under its influence is invalid. Legal standards require that the client be alert, oriented, and capable of understanding the procedure. Proxy consent must be pursued if capacity is compromised.
Choice C rationale: When a client is under the influence of opioids and lacks decision-making capacity, consent must be obtained from a legally authorized representative, such as a relative or healthcare proxy. Morphine alters consciousness and impairs executive function, making the client temporarily incompetent. Legal surrogates are empowered to make healthcare decisions in such cases. This ensures ethical compliance and protects patient rights. The nurse must verify documentation of proxy authority before proceeding with consent.
Choice D rationale: Delaying the procedure may be necessary if no authorized proxy is available, but it is not the first action. The priority is to identify and contact a legally authorized representative to obtain valid consent. Delays can compromise care, especially in urgent surgical cases. The nurse must act promptly to secure proxy consent, ensuring procedural integrity and patient safety. Only if no proxy is reachable should delay be considered, with documentation of rationale.
Similar Questions
When preparing to administer medications, the nurse carefully confirms the drug order and the patient's identity. This adherence to an essential ethical principle is:
A. Maleficence
Option A refers to wrongdoing or misconduct and is not applicable in this situation.
B. Non-maleficence
When preparing to administer medications, the nurse carefully confirms the drug order and the patient's identity. This adherence to an essential ethical principle is Non-maleficence. Non-maleficencerefers to the principle of "do no harm" and requires healthcare providers to avoid causing harm to their patients.
C. Veracity
Option C refers to truthfulness and honesty, but it is not the primary principle being demonstrated in this situation.
D. Justice
Option D refers to fairness and equality, but it is not the primary principle being demonstrated in this situation.
Full Explanation
When preparing to administer medications, the nurse carefully confirms the drug order and the patient's identity. This adherence to an essential ethical principle is Non-maleficence. Non-maleficence refers to the principle of "do no harm" and requires healthcare providers to avoid causing harm to their patients.
Option A refers to wrongdoing or misconduct and is not applicable in this situation.
Option C refers to truthfulness and honesty, but it is not the primary principle being demonstrated in this situation.
Option D refers to fairness and equality, but it is not the primary principle being demonstrated in this situation.
A nurse asks an assistive personnel (AP) to take a specimen to the laboratory, and the AP refuses. Which of the following actions should the nurse take?
A. Discuss the incident with the AP.
If an assistive personnel (AP) refuses to take a specimen to the laboratory, the nurse should first discuss the incident with the AP. This allows the nurse to understand the reasons for the refusal and to address any concerns or issues that may have led to the refusal.
B. Complete an incident report.
Option B may be necessary at some point, but it should not be the first response.
C. Take the specimen to the laboratory.
Option C may also be necessary to ensure that the specimen is delivered to the laboratory in a timely manner, but it does not address the underlying issue.
D. Report the AP to the charge nurse.
Option D may also be necessary at some point, but it should not be the first response.
Full Explanation
If an assistive personnel (AP) refuses to take a specimen to the laboratory, the nurse should first discuss the incident with the AP. This allows the nurse to understand the reasons for the refusal and to address any concerns or issues that may have led to the refusal.
Option B may be necessary at some point, but it should not be the first response.
Option C may also be necessary to ensure that the specimen is delivered to the laboratory in a timely manner, but it does not address the underlying issue.
Option D may also be necessary at some point, but it should not be the first response.
A nurse working in a long-term care facility is assigned to care for four clients following the 0700 morning change-of-shift report. Which of the following clients should the nurse attend to first?
A. A client who has bronchitis, began receiving antibiotics yesterday and has a temperature of 38.3°C (101°F).
Option A may require attention, but the client's condition is stable and they are receiving treatment.
B. A client who has COPD and has an oxygen saturation of 90%.
Option B may also require attention, but an oxygen saturation of 90% is within an acceptable range for a client with COPD.
C. A client who has Alzheimer's and was restless during the night.
Option C may also require attention, but the client's restlessness during the night does not indicate an immediate need for intervention.
D. A client who has diabetes and had a 0600 blood glucose level of 60 mg/dL.
Of the four clients described, the nurse should attend to the client who has diabetes and had a 0600 blood glucose level of 60 mg/dL first. This client's blood glucose level is low and requires immediate intervention to prevent further complications.
Full Explanation
Of the four clients described, the nurse should attend to the client who has diabetes and had a 0600 blood glucose level of 60 mg/dL first. This client's blood glucose level is low and requires immediate intervention to prevent further complications.
Option A may require attention, but the client's condition is stable and they are receiving treatment.
Option B may also require attention, but an oxygen saturation of 90% is within an acceptable range for a client with COPD.
Option C may also require attention, but the client's restlessness during the night does not indicate an immediate need for intervention.
