Complete Solutions / Certified
/. Which task should the nurse delegate to the experienced unlicensed assistive
personnel (UAP)?
a. Evaluate the ability of a client to swallow ice one hour after a gastroscopy.
b. Assist a client with initial ambulation after a hip replacement using a walker.
c. Obtain a sterile urine specimen from an indwelling catheter with a closed drainage
system.
d. Change the disposable tracheostomy inner cannula when secretions become
tenacious. - Answer-✅c
Rationale: Functions of assessment, evaluation, and nursing judgment are performed
by the registered nurse (RN). The collection of sterile urine specimens falls within the
role of the UAP.
/.Four clients arrive at the mental health unit for admission at the same time. Which
client should the nurse assess first?
a. An older adult with Alzheimer's disease who is confused.
b. A young adult with phobias that interfere with daily activities.
c. An adult with schizophrenia who stopped taking medications.
d. A middle-aged adult with acute mania who is pacing the hallway. - Answer-✅d
Rationale: The nurse should first assess the client with symptoms of mania and
hyperactivity because if the client's judgment is extremely poor, there is a potential for
risk of injury to self and others, and the client may need constant observation. The other
clients can be monitored by another staff member until the nurse can complete the
assignments.
/.According to Gardner's Leadership model, which nursing role is most involved in
representing the nursing unit service and the organization to staff, other departments,
professional disciplines, and the community?
a. Nurse manager.
b. Unit staff nurse.
c. Nurse executive.
d. Nurse researcher. - Answer-✅a
Rationale: The nurse manager's role is most involved in representing the nursing unit
service and the organization to staff, other departments, professional disciplines, and
the community, according to Gardner's Leadership model. Unit staff nurses represent
the nursing profession and the organization to clients and their families, and nurse
,executives represent the organization more generally to internal and external
constituents.
/.Female client signed a living will document two years ago that requested no heroic
measures be taken on her behalf. Today she is admitted 6 hours after the onset of left
hemiplegia, left-sided neglect, and hemianopsia. When the neurologist asks the client if
she wants to be ventilated, she responds, "If it will help." The daughter asks the nurse
what the family should do because the ventilator places her frail mother at risk for other
complications and is contrary to her mother's original request, which was executed
when she was healthy. What information is best for the nurse to provide?
a. Client's original request based on the signed living will for no heroic measures should
be followed.
b. Family should be guided to support the client's current decision.
c. Client's cognitive ability should be evaluated before the use of a ventilator is needed.
d. Family should discuss alternative treatment options with the HCP. - Answer-✅b
Rationale: The client's verbalization to accept the ventilator or other treatment should be
honored because it is sufficient validation to revoke the client's living will. If the client is
cognizant and can make their own decisions, then the living will stands. If the client
becomes unable to make their own decisions, then the family knows what course the
client wishes to take.
/.The nurse is caring for a client with rhabdomyolysis after sustaining multiple crushing
injuries. Which intervention should the nurse include in the plan of care to prevent acute
renal failure?
a. Central venous catheter insertion for hydration.
b. Blood specimen collection for electrolyte analysis.
c. Antiinflammatory and opioid analgesics for pain.
d. Diuretic IV administration for third-spacing fluids. - Answer-✅a
Rationale: Crushing injuries release myoglobin (rhabdomyolysis) into the circulation,
which can occlude distal renal tubules and cause acute tubular necrosis (ATN) or renal
failure. To prevent renal complications, the nurse should prepare the client for the
administration of copious IV fluids after CVC insertion to enhance urinary secretion of
myoglobin and iron byproducts.
/.On the second postoperative day, a client is pulseless, apneic, and unresponsive. In
what order should the nurse implement these nursing actions? (Arrange from first on top
to last on the bottom.)
Delegate emergency responsibilities.
Call for assistance.
Initiate chest compressions.
Ventilate the client. - Answer-✅1. Call for assistance.
2. Initiate chest compressions.
3. Ventilate the client.
4. Delegate emergency responsibilities.
, Rationale: Call for assistance, then based on the recommendations of the American
Heart Association (AHA), high-quality chest compressions should be the first action in
CPR. The sequence is compressions, airway, and breathing (CAB). Delegating
emergency responsibilities is last.
/.A client is brought to the hospital in cardiac arrest by emergency personnel who are
performing resuscitation. The spouse arrives as the client is taken into a treatment room
and asks to stay with the client. Which action should the nurse implement?
a. Insist that the spouse wait outside the room while resuscitation is being performed.
b. Allow the spouse to be present and ensure that a member of the team explains the
care given and answers questions.
c. Explain to the spouse that there will be no time for explanations during the
resuscitation efforts.
d. Advise the spouse that if unsuccessful, the resuscitation scene should not be the last
memory of a loved one. - Answer-✅b
Rationale: Research supports the positive benefits of family presence during invasive
procedures and cardiopulmonary resuscitation to clients, families, and staff. Facilitating
family presence allows the family to view themselves as active participants and
completes the last step of the secondary survey in the care of an emergency client.
Someone should be assigned to the family to explain the care being delivered and to
answer questions.
/.A nurse is concerned about the way medications are being administered in the nursing
unit. Which action should this nurse implement?
a. Discuss concerns with other nurses on the unit.
b. Continue with the present unit policy and procedures.
c. Propose an alternative method to administer the medications.
d. Relay the perceived problem to the director of nursing services. - Answer-✅c
Rationale: To facilitate change, an alternative method should be suggested to
managerial nursing staff.
/.Which resources should the nurse utilize when faced with an ethical dilemma? (Select
all that apply.)
a. Institutional policy.
b. Personal judgment.
c. Trusted colleagues.
d. Legal precedent.
e. Personal feelings. - Answer-✅a, b, c, d
Rationale: Resources that are available to help nurses with ethical decision-making
include institutional policy, ethics committees, personal judgment, trusted co-workers,
and legal precedent. Personal feelings may provide insight related to a nurse's personal