Question

A nurse is reinforcing education about advance directives to a client who has end-stage liver failure. Which of the following statements by the client reflects an understanding of advance directives?

Answer 1

Correct Answers:

"l can make my health care wishes known through advance directives."

Rationale :

♦️Advance directives are legal documents that allow individuals to communicate their health care preferences in advance should they become unable to make decisions later.

♦️This statement reflects accurate understanding because it recognizes that the client’s values, treatment choices, and end-of-life wishes can be respected through this document.

♦️Advance directives typically include a living will (treatment preferences) and a durable power of attorney for health care (decision-maker designation).

♦️The nurse should ensure that the client’s directives are placed in the medical record so all care providers can access them when necessary.

♦️This promotes autonomy, dignity, and patient-centered care at the end of life.

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Answer 2

Correct Answers:

32.4

Rationale :

✍️Formula:

✔️BMI = weight (kg) ÷ height (m²)

✍️Convert height: 5 ft 4 in

✔️64 in × 0.0254

♦️1.63 m

✍️Compute:

✔️85.45 ÷ (1.63 × 1.63) = 85.45 ÷ 2.66

♦️32.4

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Answer 3

Correct Answers:

Obtain a daily weight on a client who has heart failure.

Rationale :

⏺️Measuring daily weight is a routine, stable task that does not require nursing judgment, making it safe for delegation to an assistive personnel (AP).

⏺️The nurse remains responsible for interpreting weight changes, especially sudden gains indicating fluid retention in heart failure.

⏺️This aligns with the Five Rights of Delegation, specifically the right task and right circumstances.

⏺️Delegating such tasks promotes efficient workload distribution and allows nurses to focus on higher-level assessments.

⏺️It supports continuity of care by ensuring consistent monitoring of fluid balance and response to treatment.

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Answer 4

Correct Answers:

15 degree angle

Rationale :

🟢The Mantoux test for tuberculosis screening requires a 0.1 mL intradermal injection of purified protein derivative (PPD).

🟢Injecting at a 15° angle allows the solution to enter just beneath the epidermis, forming a small wheal or bleb.

🟢The forearm is the most common site, and the injection should be performed with a tuberculin syringe and 26–27-gauge needle.

🟢Injecting too deeply invalidates the test, as the antigen must remain intradermal for accurate reading.

🟢This technique ensures proper antigen placement for reliable test interpretation at 48–72 hours.

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Answer 5

Correct Answers:

Dorsogluteal

Rationale :

🔶The dorsogluteal site is least desirable for IM injections due to proximity to the sciatic nerve and major blood vessels, increasing risk of injury.

🔶In obese patients, excess adipose tissue makes it difficult to ensure the medication reaches the muscle layer, leading to ineffective absorption.

🔶Preferred sites include the ventrogluteal and vastus lateralis muscles, which are safer and more consistent in muscle depth.

🔶Avoiding this site reduces the risk of nerve damage, pain, and hematoma formation.

🔶Evidence-based guidelines recommend ventrogluteal as the safest IM site for adults.

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Answer 6

Correct Answers:

Make sure the client understands that he is leaving against medical advice.

Rationale :

💜When a competent adult chooses to leave, the nurse must ensure the client understands the risks and is making an informed decision.

💜The nurse should explain potential complications, document the discussion, and request the client’s signature on an AMA form.

💜This action upholds autonomy while protecting the nurse and facility legally.

💜The nurse should also notify the provider but cannot physically detain or restrain the client.

💜Ensuring understanding demonstrates ethical and legal accountability in nursing practice.

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Answer 7

Correct Answers:

Right communication

Rationale :

💠The Five Rights of Delegation are: Right task, right circumstance, right person, right direction/communication, and right supervision/evaluation.

💠Right communication ensures the nurse gives clear, specific instructions about the delegated task, expected outcomes, and reporting parameters.

💠Effective communication prevents errors and omissions, promoting safe, coordinated care.

💠The nurse must confirm understanding and provide feedback as needed.

💠This principle fosters accountability and teamwork between the nurse and assistive personnel.

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Answer 8

Correct Answers:

A nurse can only access the records of clients they are actively caring for.

Rationale :

🔷Accessing client medical records is guided by HIPAA (Health Insurance Portability and Accountability Act) and facility confidentiality policies.

🔷Nurses may review only the records of patients under their direct care to protect privacy.

🔷Unauthorized access—even out of curiosity—is a HIPAA violation subject to disciplinary and legal action.

🔷Confidential information should be shared only with the interprofessional team involved in the client’s care.

🔷Maintaining confidentiality upholds trust, ethics, and professional integrity.

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Answer 9

Correct Answers:

13

Rationale :

✍️Formula:

✔️Flow rate (gtt/min)=Total volume (mL)×Drop factor (gtt/mL)/Time (min)

✔️1200 mL×15=18,000; 24 hr×60

1440 min

✔️18,000÷1440

12.5

◼️13 gtt/min

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Answer 10

Correct Answers:

Gathers supplies for a client scheduled for a procedure

Rationale :

🟢Effective time management involves anticipating needs and preparing in advance to optimize workflow.

🟢Gathering supplies ahead prevents delays, interruptions, and inefficiency during procedures.

🟢It demonstrates organization, prioritization, and proactive planning, core traits of professional nursing.

🟢This allows the nurse to respond swiftly to patient needs and emergencies without last-minute disorganization.

🟢Such practices enhance patient safety, teamwork, and productivity across the shift.

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QLexNursing

1 :
A nurse is reinforcing education about advance directives to a client who has end-stage liver failure. Which of the following statements by the client reflects an understanding of advance directives?

2 :
85.45 kg 5 foot 4 inches BMI = tenths position. Do not provide the unit of measurement. Only provide the number. Round to the first decimal place

3 :
A nurse is delegating care for a group of four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

4 :
A nurse is caring for a patient who is to be screened for tuberculosis. Which angle should the nurse use to inject the tuberculin-purified protein derivative?

5 :
A nurse plans to administer an intramuscular injection to an obese patient. What muscle should the nurse consider the least desirable site for an intramuscular injection in an obese adult?

6 :
A nurse is caring for a client on a medical-surgical unit who is attempting to leave the facility. Which of the following actions should the nurse take?

7 :
A nurse is preparing to delegate tasks to an assistive personnel (AP). The nurse should identify which of the following as one of the five rights of delegation?

8 :
A charge nurse is reinforcing teaching a newly licensed nurse about accessing a client's medical records. Which of the following should the nurse include?

10 :
A nurse is caring for a group of clients for the upcoming shift. Which of the following actions by the nurse indicates effective time management?

QLexNursing

1 : A nurse is reinforcing education about advance directives to a client who has end-stage liver failure. Which of the following statements by the client reflects an understanding of advance directives?

2 : 85.45 kg 5 foot 4 inches BMI = tenths position. Do not provide the unit of measurement. Only provide the number. Round to the first decimal place

3 : A nurse is delegating care for a group of four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

4 : A nurse is caring for a patient who is to be screened for tuberculosis. Which angle should the nurse use to inject the tuberculin-purified protein derivative?

5 : A nurse plans to administer an intramuscular injection to an obese patient. What muscle should the nurse consider the least desirable site for an intramuscular injection in an obese adult?

6 : A nurse is caring for a client on a medical-surgical unit who is attempting to leave the facility. Which of the following actions should the nurse take?

7 : A nurse is preparing to delegate tasks to an assistive personnel (AP). The nurse should identify which of the following as one of the five rights of delegation?

8 : A charge nurse is reinforcing teaching a newly licensed nurse about accessing a client's medical records. Which of the following should the nurse include?

10 : A nurse is caring for a group of clients for the upcoming shift. Which of the following actions by the nurse indicates effective time management?

1 :
A nurse is reinforcing education about advance directives to a client who has end-stage liver failure. Which of the following statements by the client reflects an understanding of advance directives?

2 :
85.45 kg 5 foot 4 inches BMI = tenths position. Do not provide the unit of measurement. Only provide the number. Round to the first decimal place

3 :
A nurse is delegating care for a group of four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

4 :
A nurse is caring for a patient who is to be screened for tuberculosis. Which angle should the nurse use to inject the tuberculin-purified protein derivative?

5 :
A nurse plans to administer an intramuscular injection to an obese patient. What muscle should the nurse consider the least desirable site for an intramuscular injection in an obese adult?

6 :
A nurse is caring for a client on a medical-surgical unit who is attempting to leave the facility. Which of the following actions should the nurse take?

7 :
A nurse is preparing to delegate tasks to an assistive personnel (AP). The nurse should identify which of the following as one of the five rights of delegation?

8 :
A charge nurse is reinforcing teaching a newly licensed nurse about accessing a client's medical records. Which of the following should the nurse include?

10 :
A nurse is caring for a group of clients for the upcoming shift. Which of the following actions by the nurse indicates effective time management?