Question

The physician has discussed the need for surgery with a client and has obtained informed consent. The nurse determines that the client does not understand the risks and benefits of the procedure. What is the nurse's best action?

Answer 1

Correct Answers:

Notify the physician

Rationale :

⏺Although the physician obtained informed consent, the nurse retains responsibility to ensure the client understands the risks, benefits, and nature of the procedure.

⏺If the client demonstrates lack of understanding, the nurse must immediately notify the physician.

⏺Only the provider can clarify the surgical information; the nurse cannot provide detailed procedural explanations.

⏺Failing to act would violate the principle of informed consent, which requires voluntary, informed decision-making by the client.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

Providing culturally and religiously sensitive care in body preparation.

Rationale :

🔴Immediately after death, the nurse must prioritize respectful, culturally sensitive post-mortem care.

🔴This includes honoring religious and spiritual beliefs surrounding cleansing, clothing, positioning, and rituals.

🔴Such care affirms dignity in death and supports grieving families.

🔴Timely cultural practices also preserve the body for family viewing or ritual preparation, especially within specific timeframes found in Islamic, Jewish, and other traditions.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

induce sleep.

Rationale :

✅A drug classified as a hypnotic is prescribed to induce and maintain sleep, particularly for clients experiencing insomnia or other sleep disturbances.

✅Hypnotics work on the central nervous system by promoting sedation and drowsiness, helping initiate sleep cycles.

✅Understanding medication classification helps nurses monitor for effects such as next-day sedation or dependency in long-term use.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

Alter the client's arm position

Rationale :

🔹An IV near the antecubital space may be obstructed by arm flexion or gravity.

🔹Changing the client’s arm position, such as extending it or using a support, can often restore proper flow without further intervention.

🔹Before escalating measures, nurses should assess and correct mechanical factors that may impede gravity flow or tubing patency.

🔹This is a non-invasive first-line measure.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

STAT

Rationale :

🟣The abbreviation “STAT” indicates that a medication or intervention must be performed immediately and without delay.

🟣It is used in urgent or emergency situations where timely administration is critical to prevent deterioration or stabilize the client.

🟣STAT orders require immediate action by the nurse, followed by appropriate documentation.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

a peripherally inserted central catheter

Rationale :

▶A PICC line is the preferred vascular access device for clients who require long-term intravenous therapy, such as antibiotics administered over several weeks.

▶It is inserted into a peripheral vein, usually in the upper arm, and advanced into the superior vena cava, ensuring central venous access for medications that are irritating, vesicant, or hyperosmolar, like many antibiotics.

▶The PICC reduces the need for repeated venipuncture, lowers the risk of phlebitis compared to peripheral lines, and is suitable for both inpatient and outpatient care.

▶Nurses are responsible for monitoring for signs of infection, maintaining patency, and providing client education for home management.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

lower than the piggyback medication.

Rationale :

In a gravity-fed intravenous system, the primary IV solution must be hung lower than the piggyback (secondary) medication bag to ensure that the piggyback medication infuses first.
This is achieved by using a Y-site setup, where the higher bag (piggyback) flows due to greater hydrostatic pressure.
Once the piggyback is complete, the system automatically resumes infusion of the primary IV fluid.
This technique supports sequential drug administration without manual switching and is essential for accurate medication timing and safety.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

Warmth and palpable cord along the vein

Rationale :

🟡A palpable, warm, cord-like vein indicates phlebitis, which is the inflammation of the vein's inner lining, commonly due to mechanical irritation from the catheter, chemical irritation from the infused solution, or prolonged IV placement.

🟡These signs often present with tenderness, redness, localized swelling, and warmth.

🟡Immediate nursing action includes removing the IV catheter, applying a warm compress, and notifying the provider.

🟡Continuing infusion at the site can worsen the inflammation or lead to complications such as thrombophlebitis or localized infection.

🟡Early detection and proper response prevent escalation.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

With the head of the bed elevated 30-45 degrees

Rationale :

💎Elevating the head of the bed to 30–45 degrees during enteral feeding places the client in a semi-Fowler’s or Fowler’s position, which reduces aspiration risk by promoting gastric emptying and preventing reflux.

💎This position also aids in digestion and protects the airway, especially for clients with decreased consciousness, impaired swallowing, or delayed gastric emptying.

💎It should be maintained during the feeding and for 30–60 minutes afterward to optimize safety and minimize complications like aspiration pneumonia.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

establish a venous route for clients when their condition changes.

Rationale :

👉A saline lock (intermittent IV device) provides immediate venous access without continuous IV fluid administration.

👉It is commonly used for clients who may require intermittent IV medications, emergency access, or rapid fluid administration in case of sudden clinical deterioration.

👉This setup allows for quick and efficient response to changing client conditions while minimizing the risk of infection associated with continuous infusion.

👉Nurses must ensure the saline lock remains patent with periodic flushing, typically with normal saline every 8–12 hours, and assess for signs of infiltration or phlebitis.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

QLexNursing

1 :
The physician has discussed the need for surgery with a client and has obtained informed consent. The nurse determines that the client does not understand the risks and benefits of the procedure. What is the nurse's best action?

2 :
The nurse is performing post-mortem care on a client who has just died. What nursing care should be given priority?

3 :
A drug that is classified as being a "hypnotic" means that it will:

4 :
The client's IV. placed near the right antecubital space, is running very slowly but does not appear infiltrated and does not have evidence of phlebitis. Which measure should the nurse implement to attempt to improve the flow rate of the IV?

5 :
A client requires a medication immediately. Which abbreviation would be written in the physician's order for this medication?

6 :
A client will require IV antibiotics for several weeks. Which venous access device would be most appropriate to be used for this client?

7 :
A client requires an IV antibiotic piggyback. The nurse understands that the primary IV solution with gravity flow tubing needs to be hung:

8 :
The nurse assessing a client's intravenous catheter site suspects a phlebitis based on which clinical findings?

9 :
A nurse is about to administer a bolus enteral feeding to a client who is on bedrest. How does the nurse position the client during the feeding?

10 :
A nurse caring for a client who has a peripheral intravenous saline lock understands that its purpose is to:

QLexNursing

1 : The physician has discussed the need for surgery with a client and has obtained informed consent. The nurse determines that the client does not understand the risks and benefits of the procedure. What is the nurse's best action?

2 : The nurse is performing post-mortem care on a client who has just died. What nursing care should be given priority?

3 : A drug that is classified as being a "hypnotic" means that it will:

4 : The client's IV. placed near the right antecubital space, is running very slowly but does not appear infiltrated and does not have evidence of phlebitis. Which measure should the nurse implement to attempt to improve the flow rate of the IV?

5 : A client requires a medication immediately. Which abbreviation would be written in the physician's order for this medication?

6 : A client will require IV antibiotics for several weeks. Which venous access device would be most appropriate to be used for this client?

7 : A client requires an IV antibiotic piggyback. The nurse understands that the primary IV solution with gravity flow tubing needs to be hung:

8 : The nurse assessing a client's intravenous catheter site suspects a phlebitis based on which clinical findings?

9 : A nurse is about to administer a bolus enteral feeding to a client who is on bedrest. How does the nurse position the client during the feeding?

10 : A nurse caring for a client who has a peripheral intravenous saline lock understands that its purpose is to:

1 :
The physician has discussed the need for surgery with a client and has obtained informed consent. The nurse determines that the client does not understand the risks and benefits of the procedure. What is the nurse's best action?

2 :
The nurse is performing post-mortem care on a client who has just died. What nursing care should be given priority?

3 :
A drug that is classified as being a "hypnotic" means that it will:

4 :
The client's IV. placed near the right antecubital space, is running very slowly but does not appear infiltrated and does not have evidence of phlebitis. Which measure should the nurse implement to attempt to improve the flow rate of the IV?

5 :
A client requires a medication immediately. Which abbreviation would be written in the physician's order for this medication?

6 :
A client will require IV antibiotics for several weeks. Which venous access device would be most appropriate to be used for this client?

7 :
A client requires an IV antibiotic piggyback. The nurse understands that the primary IV solution with gravity flow tubing needs to be hung:

8 :
The nurse assessing a client's intravenous catheter site suspects a phlebitis based on which clinical findings?

9 :
A nurse is about to administer a bolus enteral feeding to a client who is on bedrest. How does the nurse position the client during the feeding?

10 :
A nurse caring for a client who has a peripheral intravenous saline lock understands that its purpose is to: