A nurse is caring for a client who has named a person to serve as his health care proxy. The
client states he needs clarification about this type of advance directives. Which of the following
statements by the client indicates a need for clarification?
"I can change who I designate as my health care proxy at any time."
c "I have to choose a family member as my health proxy."
"If I become incapacitated, end-of-life choices will be made by my proxy."
"I have to choose a family member as my health proxy."
"The health care proxy does not go into ettect until I am incapable of making decisions."
A nurse is caring for a client who is unresponsive following a car crash. The client's son states
that he does not want any heroic measures performed. Which of the following responses by
the nurse is appropriate?
"Let's wait to see if your father's condition improves before we talk about this."
d "Does your father have advance health care directives?"
"Do you think everyone in the family agrees with you?"
"If I were you, I would let the doctor know about your wishes when she makes rounds today."
"Does your father have advance health care directives?"
A nurse is caring for a client who has severe head injuries and is declared brain dead. The
transplant coordinator has spoken with the client's family about organ donation. The client's
spouse states she is confused and does not know what she should do. Which of the following
responses by the nurse is appropriate?
"There is such a shortage of organs in this country, so I think you should go ahead and
consent to donate your spouse's organs." b "What do you think your spouse would have wanted?"
"What do you think your spouse would have wanted?"
"Most religions support organ donation, so don't let that stand in the way."
"Don't you think you will feel a little better about the situation if you donate your spouse's
organs?"
An older adult client is scheduled to have an elective surgical procedure and informs the nurse
that she wants to be designated as a "do not resuscitate" (DNR) case. Which of the following
responses should the nurse provide?
"This is a minor procedure; there is no need for this request."
d "Your provider needs to talk with you concerning your request."
"You need to let your provider know your wishes after the procedure."
"You need to discuss your request with the hospital chaplain."
"Your provider needs to talk with you concerning your request."
A nurse is caring for a client who has a history of dementia. The client is alert and oriented to
person, place, and time, and has advance directives. The client is scheduled for a procedure
that requires informed consent. Which of the following persons should sign the informed b The client
consent?
, The client's partner
The client
The client's daughter, who is the primary caregiver
The client's son, who has durable power of attorney
A charge nurse notes that a statt nurse delegates an unfair share of tasks to the assistive
personnel (AP) and the nurses on next shift report the statt nurse frequently leaves tasks
uncompleted. Which of the following statements should the charge nurse make to resolve
this conflict?
"I need to talk to you about unit expectations regarding delegating and completing tasks." a "I need to talk to you about unit expectations regarding delegating and completing tasks."
"Several statt members have commented that you don't do your fair share of the work."
"If you don't do your share of the work, I will have to inform the nurse manager."
"You have been very inconsiderate of others by not completing your share of the work."
A nurse is caring for a client who has borderline personality disorder (BPD). As part of the
client's plan of care, the nurse reviews the day's schedule with the client each morning. As the
nurse begins to review the schedule with the client, the client says, "Why don't you shut up
already? I can read it myself, you know!" Which of the following responses should the nurse
give the client?
b "I don't like it when you address me with that tone of voice."
"We do this every day. Why are you so angry with me this morning?"
"I don't like it when you address me with that tone of voice."
"I know you can, but are you going to read it or not?"
"Fine. Here is the schedule, and I will expect you to be on time to your therapies."
A nurse manager received a client request not to have a specific statt nurse care for her while at
the acute care facility. Which of the following is the appropriate action by the nurse manager?
Ask other statt nurses about the level of care the specific statt nurse provides. b Address the concern with the specific statt nurse.
Address the concern with the specific statt nurse.
Recommend the specific statt nurse be transferred to another unit.
Notify the human resources department about the request.
A nurse in a long-term care facility has assigned a task to an assistive personnel (AP). The AP
refuses to perform the task. Which of the following is an appropriate statement for the nurse
to make?
"I feel you are being inconsiderate of the other team members." c "I need to talk to you about the unit policies regarding client assignments."
"I have to let the director of nursing know about this situation."
"I need to talk to you about the unit policies regarding client assignments."
"You always get your choice of assignment and don't work your fair share."
A nurse in a mental health facility is caring for a client who is upset about the loss of
privileges due to repetitive negative behavior. Which of the following statements by the nurse
demonstrates the ettective use of assertive communication?
"You were made aware of the consequences of negative behavior." b "I understand that you are angry. However, I followed the appropriate protocol."
"I understand that you are angry. However, I followed the appropriate protocol."
"You need to calm down before discussing this matter any further."
"Why did you make the choice to behave negatively?"
, A nurse is preparing to discharge a child who has a new prescription for an oral antibiotic.
Which of following information should the nurse include in the discharge instructions? (Select
all that apply.)
The reason why the child is taking the medication a The reason why the child is taking the medication
b Written information about the medication
Written information about the medication
d The adverse ettects of the medication
Stopping the medication when the child feels better
The adverse ettects of the medication
Using a kitchen spoon to administer the medication
A charge nurse is providing an inservice for statt nurses on the use of new IV pumps. Which
of the following actions should the charge nurse take to best evaluate statt competency with
the new equipment?
b Allow time during the workday when each nurse can demonstrate proficiency.
Ask each nurse to read the procedure and sign a form acknowledging competency.
Allow time during the workday when each nurse can demonstrate proficiency.
Require each nurse to take a written examination about the new equipment.
Verbally question the statt about the new equipment.
A nurse is planning preoperative care for a client who will undergo surgery. Which of the
following is the priority action by the nurse?
Determine what the client knows about the surgery. a Determine what the client knows about the surgery.
Identify the client's usual coping mechanisms.
Review the client's current home environment.
Discuss if family members will assist with postoperative care.
A nurse is teaching an adult client who has a low literacy level about self administration of a
subcutaneous medication. Which of the following strategies should the nurse use to promote
the client's understanding?
Provide a long teaching session. c Ask the client to demonstrate the skill.
Provide the client with written materials using large print.
Ask the client to demonstrate the skill.
Simplify terms using acronyms.
A nurse is preparing an older adult client for a physical examination the provider is about to
perform. Which of the following actions should the nurse take?
Explain to the client what is about to happen. a Explain to the client what is about to happen.
Make sure the room temperature is cool.
Provide music as an environmental distraction.
Inform the client that the provider will examine sensitive areas first.
A nurse is caring for a client who is at risk for falls. Which of the following actions should the
nurse take? (Select all that apply.)
b,c,d
Keep the client's room dark at night. Teach the client to use the call light.
Teach the client to use the call light.
client states he needs clarification about this type of advance directives. Which of the following
statements by the client indicates a need for clarification?
"I can change who I designate as my health care proxy at any time."
c "I have to choose a family member as my health proxy."
"If I become incapacitated, end-of-life choices will be made by my proxy."
"I have to choose a family member as my health proxy."
"The health care proxy does not go into ettect until I am incapable of making decisions."
A nurse is caring for a client who is unresponsive following a car crash. The client's son states
that he does not want any heroic measures performed. Which of the following responses by
the nurse is appropriate?
"Let's wait to see if your father's condition improves before we talk about this."
d "Does your father have advance health care directives?"
"Do you think everyone in the family agrees with you?"
"If I were you, I would let the doctor know about your wishes when she makes rounds today."
"Does your father have advance health care directives?"
A nurse is caring for a client who has severe head injuries and is declared brain dead. The
transplant coordinator has spoken with the client's family about organ donation. The client's
spouse states she is confused and does not know what she should do. Which of the following
responses by the nurse is appropriate?
"There is such a shortage of organs in this country, so I think you should go ahead and
consent to donate your spouse's organs." b "What do you think your spouse would have wanted?"
"What do you think your spouse would have wanted?"
"Most religions support organ donation, so don't let that stand in the way."
"Don't you think you will feel a little better about the situation if you donate your spouse's
organs?"
An older adult client is scheduled to have an elective surgical procedure and informs the nurse
that she wants to be designated as a "do not resuscitate" (DNR) case. Which of the following
responses should the nurse provide?
"This is a minor procedure; there is no need for this request."
d "Your provider needs to talk with you concerning your request."
"You need to let your provider know your wishes after the procedure."
"You need to discuss your request with the hospital chaplain."
"Your provider needs to talk with you concerning your request."
A nurse is caring for a client who has a history of dementia. The client is alert and oriented to
person, place, and time, and has advance directives. The client is scheduled for a procedure
that requires informed consent. Which of the following persons should sign the informed b The client
consent?
, The client's partner
The client
The client's daughter, who is the primary caregiver
The client's son, who has durable power of attorney
A charge nurse notes that a statt nurse delegates an unfair share of tasks to the assistive
personnel (AP) and the nurses on next shift report the statt nurse frequently leaves tasks
uncompleted. Which of the following statements should the charge nurse make to resolve
this conflict?
"I need to talk to you about unit expectations regarding delegating and completing tasks." a "I need to talk to you about unit expectations regarding delegating and completing tasks."
"Several statt members have commented that you don't do your fair share of the work."
"If you don't do your share of the work, I will have to inform the nurse manager."
"You have been very inconsiderate of others by not completing your share of the work."
A nurse is caring for a client who has borderline personality disorder (BPD). As part of the
client's plan of care, the nurse reviews the day's schedule with the client each morning. As the
nurse begins to review the schedule with the client, the client says, "Why don't you shut up
already? I can read it myself, you know!" Which of the following responses should the nurse
give the client?
b "I don't like it when you address me with that tone of voice."
"We do this every day. Why are you so angry with me this morning?"
"I don't like it when you address me with that tone of voice."
"I know you can, but are you going to read it or not?"
"Fine. Here is the schedule, and I will expect you to be on time to your therapies."
A nurse manager received a client request not to have a specific statt nurse care for her while at
the acute care facility. Which of the following is the appropriate action by the nurse manager?
Ask other statt nurses about the level of care the specific statt nurse provides. b Address the concern with the specific statt nurse.
Address the concern with the specific statt nurse.
Recommend the specific statt nurse be transferred to another unit.
Notify the human resources department about the request.
A nurse in a long-term care facility has assigned a task to an assistive personnel (AP). The AP
refuses to perform the task. Which of the following is an appropriate statement for the nurse
to make?
"I feel you are being inconsiderate of the other team members." c "I need to talk to you about the unit policies regarding client assignments."
"I have to let the director of nursing know about this situation."
"I need to talk to you about the unit policies regarding client assignments."
"You always get your choice of assignment and don't work your fair share."
A nurse in a mental health facility is caring for a client who is upset about the loss of
privileges due to repetitive negative behavior. Which of the following statements by the nurse
demonstrates the ettective use of assertive communication?
"You were made aware of the consequences of negative behavior." b "I understand that you are angry. However, I followed the appropriate protocol."
"I understand that you are angry. However, I followed the appropriate protocol."
"You need to calm down before discussing this matter any further."
"Why did you make the choice to behave negatively?"
, A nurse is preparing to discharge a child who has a new prescription for an oral antibiotic.
Which of following information should the nurse include in the discharge instructions? (Select
all that apply.)
The reason why the child is taking the medication a The reason why the child is taking the medication
b Written information about the medication
Written information about the medication
d The adverse ettects of the medication
Stopping the medication when the child feels better
The adverse ettects of the medication
Using a kitchen spoon to administer the medication
A charge nurse is providing an inservice for statt nurses on the use of new IV pumps. Which
of the following actions should the charge nurse take to best evaluate statt competency with
the new equipment?
b Allow time during the workday when each nurse can demonstrate proficiency.
Ask each nurse to read the procedure and sign a form acknowledging competency.
Allow time during the workday when each nurse can demonstrate proficiency.
Require each nurse to take a written examination about the new equipment.
Verbally question the statt about the new equipment.
A nurse is planning preoperative care for a client who will undergo surgery. Which of the
following is the priority action by the nurse?
Determine what the client knows about the surgery. a Determine what the client knows about the surgery.
Identify the client's usual coping mechanisms.
Review the client's current home environment.
Discuss if family members will assist with postoperative care.
A nurse is teaching an adult client who has a low literacy level about self administration of a
subcutaneous medication. Which of the following strategies should the nurse use to promote
the client's understanding?
Provide a long teaching session. c Ask the client to demonstrate the skill.
Provide the client with written materials using large print.
Ask the client to demonstrate the skill.
Simplify terms using acronyms.
A nurse is preparing an older adult client for a physical examination the provider is about to
perform. Which of the following actions should the nurse take?
Explain to the client what is about to happen. a Explain to the client what is about to happen.
Make sure the room temperature is cool.
Provide music as an environmental distraction.
Inform the client that the provider will examine sensitive areas first.
A nurse is caring for a client who is at risk for falls. Which of the following actions should the
nurse take? (Select all that apply.)
b,c,d
Keep the client's room dark at night. Teach the client to use the call light.
Teach the client to use the call light.
