Question

A nurse is providing teaching to a client about advance directive. Which of the following statements by the client indicates an understanding of the teaching?

Answer 1

Correct Answers:

My durable power of attorney for health care is part of my advance directives:

Rationale :

◼An advance directive is a legal document that includes the durable power of attorney for health care, which appoints a surrogate decision-maker, and a living will, which outlines treatment preferences.

◼The durable power of attorney becomes effective when the client is unable to make their own health care decisions.

◼This ensures that care aligns with the client’s wishes. Understanding this distinction is essential for informed decision-making and legally sound planning.

Distractor Analysis :

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Answer 2

Correct Answers:

Provide the client with information on treatment options and outcomes,

Rationale :

📌When a client declines a recommended procedure, the nurse must respect autonomy while ensuring informed decision-making.

This includes offering nonjudgmental education about available options and expected outcomes.
Providing this information empowers the client to make a decision that aligns with their values and health goals.
It is not appropriate to pressure the client or assume mental incapacity without cause.

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Answer 3

Correct Answers:

Reinforcing dietary teaching with a client who has heart disease

Rationale :

◼LPNs may reinforce teaching already initiated by the RN, especially on topics like dietary management for chronic illness.

◼This task stays within the scope of the LPN and supports continuity of care.

◼The other tasks require either initial teaching or professional judgment, which are responsibilities of the RN.

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Answer 4

Correct Answers:

Offer to place the purse in the facility safe.

Rationale :

✅Safeguarding personal items is the nurse’s responsibility.

✅Placing valuables in the facility safe is the most secure method and aligns with institutional policy.

✅ Leaving items in unsecured locations puts them at risk for loss or theft, which can compromise client trust and safety.

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Answer 5

Correct Answers:

Instruct the AP to discontinue the conversation.

Rationale :

When a nurse observes a breach in confidentiality, immediate action must be taken to stop the violation.
Instructing the APs to stop protects client privacy.
Additional steps such as education or documentation may follow but are not the priority in the moment.

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Answer 6

Correct Answers:

Change peripheral IV primary tubing every 96 hr.

Rationale :

🔶Changing IV tubing every 96 hours is both safe and cost-effective, following CDC guidelines.

🔶 Other options increase infection risk or violate current evidence-based practice.

🔶 Cost containment involves balancing safety and efficiency.

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Answer 7

Correct Answers:

The time the client received his last dose of pain medication

Rationale :

🔹Essential shift report content includes timing of last medications, especially for pain management

🔹This information helps maintain therapeutic effects and avoid delays or overdoses.

🔹Personal preferences or speculative details should be excluded.

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Answer 8

Correct Answers:

Develop a clinical question.

Rationale :

✔The first step in evidence-based practice (EBP) is identifying a focused clinical question, often using the PICO format.

✔This drives the search for applicable evidence and ensures relevance to clinical concerns.

✔Without a question, research lacks direction.

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Answer 9

Correct Answers:

A client who has a compromised airway

Rationale :

🔹Clients with airway compromise receive red tag priority in disaster triage.

🔹These individuals need immediate intervention and have a high chance of survival with prompt care.

🔹Others with fatal or less urgent conditions get lower priority tags.

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Answer 10

Correct Answers:

Prepare to administer antibiotics to the client.

Rationale :

🔸Cutaneous anthrax is treated with antibiotics, not antivirals.

Early treatment prevents systemic spread.
While airborne precautions are needed for inhalation anthrax, cutaneous form primarily requires wound care and antibiotics.

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RN Leadership 2023

No.

1 : A nurse is providing teaching to a client about advance directive. Which of the following statements by the client indicates an understanding of the teaching?

2 : A nurse is caring for a client who has uterine prolapse. The provider has recommended a total abdominal hysterectomy, but the client tells the nurse that the surgery is not an option. Which of the following is an appropriate action for the nurse to take?

3 : A nurse on a medical surgical unit is caring for a group of clients with the assistance of a licensed practical nurse (LPN) and assistive personnel. Which of the following tasks should the nurse assign to the LPN?

4 : A nurse is preparing a client for surgery. The client expresses concern that someone might steal her purse during the procedure. Which of the following actions should the nurse take?

5 : A nurse overhears two assistive personnel (AP) discussing a client's care in the cafeteria. Which of the following actions should the nurse take?

6 : A nurse is serving on a committee whose task is to plan cost- effective care at the facility. Which of the following client care tasks should the nurse recommend?

7 : A nurse on a surgical unit is preparing to transfer a client to a rehabilitation facility. Which of the following information should the nurse include in the change-of-shift report?

8 : A nurse is teaching a class of newly licensed nurses about evidence-based practice. The nurse should include which of the following as the first step in evidence-based practice?

9 : A nurse in an emergency department is triaging four clients following a mass casualty event. To which of the following clients should the nurse assign a red tag?

10 : A nurse in the emergency department admits a client who has been exposed to cutaneous anthrax. Which of the following actions should the nurse take?

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