Question

A nurse is caring for a client who has a tumor. The provider recommends surgery. The client refuses, but the client's partner wants the surgery performed. Which of the following is the deciding factor in determining if the surgery will be done?

Answer 1

Correct Answers:

Whether the partner is the client's durable power of attorney for health care

Rationale :

The primary decision-making authority regarding medical procedures belongs to the client, as long as they are alert, oriented, and competent.
However, if the client becomes unable to make decisions, the designated durable power of attorney for health care (DPOA-HC) has legal authority to make medical decisions.
In this scenario, the partner's preference would only be valid if they are the appointed DPOA-HC.
Factors like religious beliefs or ethics committee opinions do not override the client’s autonomy unless they are incapacitated and a surrogate decision-maker has been designated.

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Answer 2

Correct Answers:

Ask the client's son to go to the waiting area

Rationale :

✔When elder abuse is suspected, the nurse must ensure the client is assessed privately and safely.

✔Asking the son to step out of the room allows the nurse to speak to the client without coercion, fear, or interference, which is critical for obtaining accurate and honest information.

✔Assessing the client in front of the suspected abuser violates privacy and can lead to underreporting.

✔ Filing an incident report is for internal use but doesn't replace direct assessment, and discharging without full evaluation would breach duty of care.

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Answer 3

Correct Answers:

Black

Rationale :

🧩In disaster triage, a black tag is assigned to clients with injuries that are non-survivable or who are expected to die, such as someone with full-thickness burns over 72% of the body.

🧩These clients require extensive resources with minimal likelihood of survival, especially in mass casualty incidents where resources must be prioritized for those with better prognoses.

🧩 Red is for emergent but potentially survivable injuries, yellow for delayed care, and green for minor injuries.

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Answer 4

Correct Answers:

"A health care proxy can make decisions for you when you are unable to do so"

Rationale :

◽A health care proxy is a form of advance directive in which the client designates someone to make medical decisions only if they become incapacitated.

◽ The nurse should provide accurate, clear, and supportive education on this topic.

◽The proxy does not need to be a family member, and an attorney is not required to approve it.

◽The timing (such as before surgery) is not as important as ensuring the client understands the proxy’s role and completes the documentation properly.

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Answer 5

Correct Answers:

Continue the medication dosages that relieve the client's pain

Rationale :

🔸In hospice and palliative care, the primary goal is comfort and relief from suffering, even if medications such as opioids and benzodiazepines cause sedation.

🔸The double effect principle supports this: if the intent is to relieve pain—not to hasten death—then symptom management is ethically acceptable.

🔸Adjusting or withholding medications may lead to uncontrolled pain and suffering.

🔸 This approach aligns with best practices in end-of-life care, prioritizing quality of life over prolongation of life.

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Answer 6

Correct Answers:

"l should encrypt personal health information when sending emails"

Rationale :

💨Client confidentiality is a legal and ethical responsibility of all healthcare providers, and safeguarding electronic health information is essential.

💨Emails containing protected health information (PHI) must be encrypted to prevent unauthorized access and ensure HIPAA compliance.

💨Using another nurse's password violates security protocols, and discarding PHI documents in the trash is a breach of confidentiality.

💨While posting vital signs in the client's room may be acceptable in specific formats, it must comply with facility policy to ensure no identifying information is exposed.

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Answer 7

Correct Answers:

A client who is scheduled for an endoscopy later today and requires an enema

Rationale :

🔦Licensed Practical Nurses (LPNs) can perform routine procedures such as administering enemas and preparing clients for diagnostic tests like endoscopy, which are within their scope of practice.

🔦However, they cannot perform initial assessments, develop care plans, or provide initial teaching, all of which are responsibilities of the RN.

🔦Assigning an LPN to stable or routine care tasks promotes safe delegation and efficient care delivery while respecting licensure boundaries.

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Answer 8

Correct Answers:

A client who has peripheral vascular disease and has an absent pulse in the right foot

Rationale :

🎲An absent peripheral pulse in a client with peripheral vascular disease may indicate acute arterial occlusion, which is a vascular emergency requiring immediate intervention to preserve limb viability.

🎲This client is the priority due to potential loss of perfusion.

🎲While urinary retention after laminectomy is urgent, and crying before surgery is emotionally important, they are not as time-sensitive or life-altering as compromised circulation.

🎲Dressing changes can be scheduled, making them a lower priority.

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Answer 9

Correct Answers:

Help the AP assist the client with the transfer

Rationale :

🦠When a nurse observes an assistive personnel (AP) performing an unsafe transfer, the priority is client safety.

🦠The nurse should intervene immediately to prevent injury to the client or the AP.

🦠While teaching and referencing procedures are important, they should follow after the immediate safety concern is addressed.

🦠Assisting first ensures the client is safe, then the nurse can offer proper instruction or correction to the AP.

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Answer 10

Correct Answers:

Help the AP assist the client with the transfer

Rationale :

🦠When a nurse observes an assistive personnel (AP) performing an unsafe transfer, the priority is client safety.

🦠The nurse should intervene immediately to prevent injury to the client or the AP.

🦠While teaching and referencing procedures are important, they should follow after the immediate safety concern is addressed.

🦠Assisting first ensures the client is safe, then the nurse can offer proper instruction or correction to the AP.

Distractor Analysis :

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QLexNursing

1 : A nurse is caring for a client who has a tumor. The provider recommends surgery. The client refuses, but the client's partner wants the surgery performed. Which of the following is the deciding factor in determining if the surgery will be done?

2 : A nurse is assessing an older adult client who was brought to the emergency department by his adult son, who reports that the client fell at home. The nurse suspect's elder abuse. Which of the following actions should the nurse take?

3 : A nurse is conducting a disaster preparedness drill with a group of nurses who are orienting to the facility. Which of the following triage tag colors should the nurse instruct the group to apply to a client who has full thickness burns on 72% of his body?

4 : A nurse on a medica-surgical unit is caring for a client who asks about advance directives and states that he wants to appoint a health care proxy. Which of the following responses should the nurse make?

5 : A hospice nurse is caring for a client who has terminal illness and reports severe pain. After the nurse administers the prescribed opioid and benzodiazepine, the client becomes somnolent and difficult to arouse. Which of the following actions should the nurse take?

6 : A nurse is orienting a newly licensed nurse about client confidentiality. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

7 : A nurse is delegating care for a group of clients. Which of the following clients should the nurse assign to the LPN?

8 : A nurse on a med-surge unit is caring for four clients. The nurse should recognize that which of the following clients is the priority?

9 : A nurse manager observes assistive personnel (AP) incorrectly transferring a client to the bedside commode. Which of the following actions should the nurse take first?

10 : A nurse manager observes assistive personnel (AP) incorrectly transferring a client to the bedside commode. Which of the following actions should the nurse take first?