Question

A nurse is completing a preoperative checklist for a client. The client tells the nurse. "I am not sure if I want the procedure after all." Which of the following responses should the nurse make?

Answer 1

Correct Answers:

"I will contact the provider to let her know."

Rationale :

🟡 Clients have the right to informed consent, which includes the right to withdraw consent at any time, even just before the procedure.

🟡 The nurse must act as an advocate, ensuring the client's autonomy and decision-making are respected without pressure.

🟡 Reporting the client's hesitation to the provider ensures that a thorough discussion can occur between the provider and the client regarding risks, benefits, and alternatives.

🟡 The nurse should not try to persuade, judge, or dismiss the client’s concerns but should prioritize communication with the healthcare team.

🟡 Timely notification allows for re-evaluation of consent, ensuring the client proceeds with full understanding and voluntary agreement.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

Access the nursing information system for guidelines about blood transfusions.

Rationale :

🟪 Accessing the nursing information system allows the nurse to review current protocols, policies, and procedures related to blood transfusions, ensuring that care is safe, standardized, and evidence-based.

🟪 Reviewing guidelines is a critical preparatory step that helps the nurse understand what actions must be taken before, during, and after the transfusion (e.g., verification steps, monitoring for reactions).

🟪 The nurse is responsible for reviewing institutional resources when unfamiliar or needing a refresher on a procedure to promote safe, informed practice.

🟪 This promotes accountability and prevents avoidable errors, especially for high-risk interventions like transfusions.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

ADL

Rationale :

🔵 "ADL" (Activities of Daily Living) is a widely accepted and approved abbreviation used in healthcare to describe a patient's basic self-care tasks such as bathing, dressing, toileting, and eating.

🔵 It is on the list of safe, standard abbreviations endorsed by many healthcare facilities and professional organizations for clear communication.

🔵 Abbreviations like "AU" (both ears), "HS" (bedtime or half-strength), and "SQ" (subcutaneous) are discouraged or included on the Joint Commission’s “Do Not Use” list due to their potential for misinterpretation and medication errors.

🔵 Using only approved abbreviations is essential for maintaining legal, accurate, and unambiguous documentation in client records.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

Verify the medication name along with its intended purpose.

Rationale :

🔶 When receiving telephone prescriptions, it is essential to verify both the name of the medication and its purpose to reduce the risk of medication errors due to sound-alike or look-alike drug names.

🔶 This verification ensures the nurse and provider are in complete agreement about the prescription’s intent, especially for medications with multiple uses (e.g., propranolol for hypertension, anxiety, or migraines).

🔶 The Joint Commission recommends using "read-back" techniques, which include confirming drug name, dosage, route, frequency, and the indication to ensure safety.

🔶 Clarifying the purpose is a key part of safe medication communication, particularly during verbal or telephone orders that are more prone to errors.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

Failing to notify the provider after a medication error

Rationale :

🔸 Negligence is defined as a failure to take proper care or act in a reasonable, prudent manner, which results in harm or potential harm to the client.

🔸 Failing to notify the provider after a medication error meets this definition because it delays necessary interventions that could mitigate harm and compromises client safety.

🔸 Nurses have a duty to report all errors immediately, no matter the perceived severity, to uphold professional standards and protect the client.

**🔸 Negligence is an unintentional tort, and in this scenario, the omission of action places the client at risk, making it a clear example of negligent behavior.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

Establish eye contact with the other person.

Rationale :

🔷 Establishing eye contact is a key component of effective communication and conflict resolution, as it conveys attentiveness, respect, and sincerity.

🔷 It promotes active listening and demonstrates engagement in the conversation, helping to de-escalate tension and foster mutual understanding.

**🔷 Conflict resolution relies on professional interpersonal skills, including nonverbal cues like eye contact, calm posture, and open body language.

**🔷 The goal is to resolve the issue through constructive dialogue, not to personalize or escalate the conflict, and maintaining eye contact supports that objective.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

Check the family member's vital signs.

Rationale :

🟥 The priority action in any unexpected medical event is to assess the person’s condition, and in this case, that means evaluating the family member’s vital signs to determine their immediate physiological status.

🟥 This aligns with the nursing process — first step: assessment. Without knowing the family member's baseline or current condition, no further decisions can be safely made.

🟥 Prompt assessment can identify urgent concerns such as hypotension, bradycardia, or other issues that may have led to the fainting episode.

🟥 Vital sign evaluation provides critical data for guiding next steps, whether it's supportive care, emergency intervention, or simply observation.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

Activate the alarm outside the client's room.

Rationale :

🟠 According to the RACE protocol for fire safety (Rescue, Alarm, Contain, Extinguish/Evacuate), the next step after removing the client (Rescue) is to activate the fire alarm (Alarm) to alert others and initiate the facility’s emergency response.

🟠 Prompt activation of the alarm ensures that the fire department and internal emergency team are notified immediately, allowing coordinated response and evacuation if necessary.

🟠 Delaying the alarm could result in increased risk to other clients, staff, and property if the fire spreads before professional responders are mobilized.

🟠 Fire protocols are designed to prioritize safety and rapid communication, making alarm activation a critical and time-sensitive step.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

Tell the client's partner to ask the client about the results.

Rationale :

🔴 Under HIPAA (Health Insurance Portability and Accountability Act), client health information is confidential and cannot be shared without explicit permission from the client.

🔴 Even if the partner is a close relative or spouse, they are not automatically authorized to receive private health information unless the client consents.

🔴 Encouraging the partner to ask the client directly respects the client’s autonomy and maintains legal and ethical confidentiality standards.

🔴 Nurses are responsible for protecting patient privacy, and sharing information without consent can result in legal consequences and breaches of trust.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

Collect the relevant facts.

Rationale :

🟡 The first step in addressing any ethical dilemma is to gather all relevant information to fully understand the situation before taking action.

🟡 This includes reviewing the child’s condition, prescribed treatment, parental objections, and applicable legal and institutional policies.

🟡 Accurate data collection helps ensure that decisions are based on objective facts rather than assumptions or personal beliefs.

🟡 A thorough understanding of the situation lays the foundation for further ethical decision-making steps such as value clarification, outcome planning, and action formulation.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

PN Management-2023

No.

1 :
A nurse is completing a preoperative checklist for a client. The client tells the nurse. "I am not sure if I want the procedure after all." Which of the following responses should the nurse make?

2 :
A nurse receives a change-of-shift report and learns that one of their assigned clients is scheduled to receive a blood transfusion. Which of the following actions should the nurse take?

3 :
A nurse in a long-term care facility is reviewing the facility documentation policies with a newly licensed nurse. Which of the following abbreviations should the nurse remind the newly licensed nurse to use when documenting care?

4 :
A nurse is receiving a telephone prescription from a provider for propranolol 40 mg PO BID. When reading back the information to the provider, which of the following actions should the nurse take?

5 :
A nurse is reinforcing teaching about torts with a newly licensed nurse. The nurse should include which of the following as an example of negligence?

6 :
A nurse is discussing conflict resolution with a group of assistive personnel. Which of the following information should the nurse include in the discussion?

7 :
A nurse is admitting a client for an elective surgical procedure. During the client interview, one of the client's family members faints. Which of the following actions should the nurse take first?

8 :
A nurse is reinforcing teaching with staff members about the protocol for extinguishing a fire in a trash can in a client's room. After removing the client from the room, which of the following actions should the nurse instruct the staff members to take next?

9 :
A nurse on a medical-surgical unit is assisting in providing care for a client. The client's partner asks the nurse about the client's laboratory results. Which of the following actions should the nurse take?

10 :
A nurse is assisting with the plan of care for a child whose parents refuse to accept the medical treatment prescribed by the provider. Which of the following actions should the nurse plan to take first to address this ethical dilemma?

Connect With Us

PN Management-2023

No.

1 : A nurse is completing a preoperative checklist for a client. The client tells the nurse. "I am not sure if I want the procedure after all." Which of the following responses should the nurse make?

2 : A nurse receives a change-of-shift report and learns that one of their assigned clients is scheduled to receive a blood transfusion. Which of the following actions should the nurse take?

3 : A nurse in a long-term care facility is reviewing the facility documentation policies with a newly licensed nurse. Which of the following abbreviations should the nurse remind the newly licensed nurse to use when documenting care?

4 : A nurse is receiving a telephone prescription from a provider for propranolol 40 mg PO BID. When reading back the information to the provider, which of the following actions should the nurse take?

5 : A nurse is reinforcing teaching about torts with a newly licensed nurse. The nurse should include which of the following as an example of negligence?

6 : A nurse is discussing conflict resolution with a group of assistive personnel. Which of the following information should the nurse include in the discussion?

7 : A nurse is admitting a client for an elective surgical procedure. During the client interview, one of the client's family members faints. Which of the following actions should the nurse take first?

8 : A nurse is reinforcing teaching with staff members about the protocol for extinguishing a fire in a trash can in a client's room. After removing the client from the room, which of the following actions should the nurse instruct the staff members to take next?

9 : A nurse on a medical-surgical unit is assisting in providing care for a client. The client's partner asks the nurse about the client's laboratory results. Which of the following actions should the nurse take?

10 : A nurse is assisting with the plan of care for a child whose parents refuse to accept the medical treatment prescribed by the provider. Which of the following actions should the nurse plan to take first to address this ethical dilemma?

1 :
A nurse is completing a preoperative checklist for a client. The client tells the nurse. "I am not sure if I want the procedure after all." Which of the following responses should the nurse make?

2 :
A nurse receives a change-of-shift report and learns that one of their assigned clients is scheduled to receive a blood transfusion. Which of the following actions should the nurse take?

3 :
A nurse in a long-term care facility is reviewing the facility documentation policies with a newly licensed nurse. Which of the following abbreviations should the nurse remind the newly licensed nurse to use when documenting care?

4 :
A nurse is receiving a telephone prescription from a provider for propranolol 40 mg PO BID. When reading back the information to the provider, which of the following actions should the nurse take?

5 :
A nurse is reinforcing teaching about torts with a newly licensed nurse. The nurse should include which of the following as an example of negligence?

6 :
A nurse is discussing conflict resolution with a group of assistive personnel. Which of the following information should the nurse include in the discussion?

7 :
A nurse is admitting a client for an elective surgical procedure. During the client interview, one of the client's family members faints. Which of the following actions should the nurse take first?

8 :
A nurse is reinforcing teaching with staff members about the protocol for extinguishing a fire in a trash can in a client's room. After removing the client from the room, which of the following actions should the nurse instruct the staff members to take next?

9 :
A nurse on a medical-surgical unit is assisting in providing care for a client. The client's partner asks the nurse about the client's laboratory results. Which of the following actions should the nurse take?

10 :
A nurse is assisting with the plan of care for a child whose parents refuse to accept the medical treatment prescribed by the provider. Which of the following actions should the nurse plan to take first to address this ethical dilemma?