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 :

✅Autonomy is a fundamental ethical and legal principle in health care.

✅A client who refuses a recommended surgery has the right to do so, provided they are mentally competent.

✅The partner’s preference for the surgery is only valid if the partner holds legal authority as the client’s durable power of attorney for health care (DPOA-HC).

✅Without this legal designation, the partner cannot override the client's decision.

✅ The nurse must ensure that the client’s right to make informed decisions is upheld unless a designated surrogate holds decision-making power.

Distractor Analysis :

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Answer 2

Correct Answers:

Report the infection to the local health department

Rationale :

✔Chlamydia is a notifiable sexually transmitted infection that must be reported to public health authorities under state and federal regulations.

✔Reporting ensures appropriate public health interventions, such as contact tracing and education, to reduce disease spread.

✔The nurse plays a vital role in supporting community health through mandatory disease reporting.

✔This responsibility aligns with public health policy and supports the broader goal of preventing complications and reducing transmission rates in the community.

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Answer 3

Correct Answers:

"l cannot provide this information to you without your mother's consent. "

Rationale :

🌐Confidentiality under the Health Insurance Portability and Accountability Act (HIPAA) prohibits the nurse from disclosing any client health information without the client’s explicit consent.

🌐 Even if the request comes from a family member, the nurse must safeguard the client’s privacy and refer such inquiries back to the client.

🌐Protecting private health information builds trust in the nurse-client relationship and ensures compliance with federal privacy laws.

🌐 Nurses must remain vigilant in upholding professional and legal boundaries.

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Answer 4

Correct Answers:

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

Rationale :

🔹In suspected elder abuse cases, it is essential to speak with the client privately to ensure accurate assessment and documentation.

🔹 The presence of a potential abuser, such as a family member, may inhibit the client from disclosing details.

🔹Removing the son from the room facilitates a safe and non-threatening environment.

🔹The nurse must follow legal and ethical duties to assess for abuse and ensure the client's safety while preparing for potential mandatory reporting.

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Answer 5

Correct Answers:

Black

Rationale :

💥Disaster triage systems use color-coded tags to prioritize care based on injury severity and survival likelihood.

💥A client with 72% full-thickness burns has minimal survival prospects due to extensive tissue damage and likely multi-organ failure.

💥Assigning a black tag signifies that the client will not benefit from emergent medical intervention due to the extent of injury.

💥 This approach preserves limited resources for those with a higher chance of survival and aligns with disaster response principles of resource allocation and triage ethics.

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Answer 6

Correct Answers:

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

Rationale :

☀An advance directive allows a competent adult to designate a health care proxy, who will make medical decisions if the client becomes incapacitated.

This promotes autonomy and informed decision-making.
The health care proxy does not need to be a family member, nor does it require attorney approval unless mandated by specific state laws.
The nurse’s role includes providing accurate, legally sound information to help clients make proactive choices regarding their care preferences.

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Answer 7

Correct Answers:

Continue the medication dosages that relieve the client's pain

Rationale :

🦠Clients receiving hospice or palliative care are entitled to aggressive pain management, even if medications cause sedation or respiratory depression.

🦠The primary goal of hospice care is comfort, not life prolongation.

🦠 Continuing effective opioid and benzodiazepine therapy is appropriate as long as the medication aligns with the client’s plan of care and promotes dignified end-of-life comfort.

🦠Adjusting or withholding medications due to sedation contradicts the hospice philosophy of symptom relief.

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Answer 8

Correct Answers:

I should encrypt personal health information when sending emails"

Rationale :

⭐Protecting client confidentiality includes safeguarding electronic protected health information (ePHI).

⭐Encrypting emails that contain sensitive client data prevents unauthorized access and complies with HIPAA’s privacy and security rules.

⭐This is especially important in the digital age, where health information is easily shared electronically.

⭐Nurses must use secure communication systems and avoid practices that may expose client information to breaches.

Distractor Analysis :

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Answer 9

Correct Answers:

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

Rationale :

📌Licensed practical nurses (LPNs) can provide care for clients with stable, predictable conditions, such as administering enemas for routine pre-procedure preparation.

📌This task falls within the LPN scope and does not require clinical judgment or patient teaching.

📌In contrast, initial assessments, development of care plans, and new patient education must be performed by registered nurses.

📌 Assigning this stable care task to an LPN ensures safe and appropriate delegation.

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Answer 10

Correct Answers:

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

Rationale :

🧨An absent pulse in a client with peripheral vascular disease (PVD) indicates a potential critical arterial occlusion, which is a medical emergency.

🧨Immediate assessment and intervention are needed to restore circulation and prevent tissue ischemia or limb loss.

🧨While other clients have important needs, this scenario presents the highest risk to life and limb.

🧨The nurse must recognize compromised perfusion as the top priority using the ABCs and circulation principles.

Distractor Analysis :

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RN Leadership Level 3

No.

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 caring for a client who has a new diagnosis of chlamydia. Which of the following actions should the nurse take?

3 : A nurse is caring for a client who has cancer. The client's adult child asks the nurse for information about the client's treatment plan. Which of the following responses should the nurse make?

4 : 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?

5 : 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?

6 : 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?

7 : 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?

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

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

10 : 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?

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