NCLEX-RN Nursing — All Questions

A nurse is caring for a client after a myocardial infarction. Which laboratory marker is most specific for cardiac muscle damage?

• a.Blood urea nitrogen
• b.Troponin✓
• c.Serum sodium
• d.Total white blood cell count

Troponin is the most specific and sensitive biomarker for myocardial injury and rises within hours of an infarction, guiding diagnosis and treatment.

A client has a nasogastric tube to continuous suction and develops muscle weakness. Which disturbance is most likely?

• a.Respiratory acidosis with hypernatremia
• b.Respiratory alkalosis with hypercalcemia
• c.Metabolic alkalosis with hypokalemia✓
• d.Metabolic acidosis with hyperkalemia

Loss of gastric acid and potassium through continuous suction leads to metabolic alkalosis and hypokalemia, which can cause muscle weakness and dysrhythmias.

A nurse reviews an arterial blood gas: pH 7.30, PaCO2 55 mm Hg, HCO3 24 mEq/L. How should the nurse interpret this?

• a.Metabolic alkalosis
• b.Respiratory alkalosis
• c.Metabolic acidosis
• d.Respiratory acidosis✓

A low pH with an elevated PaCO2 and a normal bicarbonate indicates uncompensated respiratory acidosis, often from hypoventilation.

A client with cirrhosis develops confusion and asterixis. Which laboratory value best explains these findings?

• a.Decreased serum glucose
• b.Elevated serum ammonia✓
• c.Elevated serum calcium
• d.Decreased white blood cell count

Impaired liver function raises serum ammonia, causing hepatic encephalopathy with confusion and asterixis. Treatment such as lactulose lowers ammonia levels.

A nurse cares for a client with acute kidney injury and a serum potassium of 6.8 mEq/L. Which finding is the priority concern?

• a.Decreased urine output over the past shift
• b.Fatigue that improves with an afternoon rest
• c.Mild peripheral edema of both ankles and feet
• d.Peaked T waves on the electrocardiogram✓

Hyperkalemia can cause life-threatening cardiac dysrhythmias; peaked T waves signal cardiac effects and require immediate intervention. The other findings are important but less urgent.

A client is admitted with dehydration. Which assessment finding supports this diagnosis?

• a.Poor skin turgor and elevated urine specific gravity✓
• b.Moist mucous membranes and brisk capillary refill
• c.Bounding pulse and elevated blood pressure with crackles
• d.Jugular vein distention while sitting upright

Dehydration produces poor skin turgor, dry mucous membranes, and concentrated urine with a high specific gravity. Jugular distention and bounding pulses suggest fluid overload.

A nurse assesses a client with hypothyroidism. Which finding is expected?

• a.Weight loss with marked heat intolerance
• b.Fatigue, cold intolerance, and bradycardia✓
• c.Tachycardia and bulging exophthalmos
• d.Frequent diarrhea and hand tremors

Hypothyroidism slows metabolism, causing fatigue, cold intolerance, weight gain, and bradycardia. Weight loss, heat intolerance, and tachycardia occur in hyperthyroidism.

A client with type 1 diabetes is diaphoretic, shaky, and confused with a blood glucose of 54 mg/dL. What is the priority intervention?

• a.Withhold all food until the provider is notified
• b.Administer long-acting insulin
• c.Encourage the client to exercise
• d.Give 15 grams of a fast-acting carbohydrate✓

These are signs of hypoglycemia. For a conscious client, giving about 15 grams of fast-acting carbohydrate raises the glucose quickly; the level is then rechecked.

A nurse is monitoring a client after a total hip replacement. Which finding suggests a possible pulmonary embolism?

• a.Decreased appetite at the evening meal
• b.Gradual improvement in hip mobility
• c.Sudden dyspnea, chest pain, and tachycardia✓
• d.Mild incisional soreness with movement

Sudden dyspnea, pleuritic chest pain, and tachycardia after orthopedic surgery suggest a pulmonary embolism, a medical emergency requiring immediate action.

A client's laboratory results show a hemoglobin of 7.2 g/dL. Which assessment finding is most consistent with this value?

• a.Bradycardia and hypertension
• b.Increased energy and alertness
• c.Fatigue, pallor, and tachycardia✓
• d.Warm, ruddy skin and bounding pulses

A hemoglobin of 7.2 g/dL indicates anemia, producing fatigue, pallor, and compensatory tachycardia due to reduced oxygen-carrying capacity.

A nurse cares for a client with increased intracranial pressure. Which finding is an early sign?

• a.Fixed, dilated pupils that do not react
• b.Cushing's triad of vital sign changes
• c.Deep coma with no motor response
• d.A change in level of consciousness✓

A change in level of consciousness is the earliest and most sensitive sign of increased intracranial pressure. Fixed pupils and Cushing's triad are late, ominous findings.

A client with Addison's disease is at risk for adrenal crisis. Which finding requires immediate intervention?

• a.Occasional craving for salty foods
• b.Mild fatigue in the afternoon
• c.Slightly bronzed skin creases
• d.Severe hypotension and hyperkalemia✓

Adrenal crisis causes profound hypotension, hyperkalemia, and hyponatremia and is life-threatening, requiring immediate fluids and hydrocortisone. Bronzing and salt craving are chronic features.

A nurse reviews arterial blood gases: pH 7.50, PaCO2 30 mm Hg, HCO3 24 mEq/L. Which condition does this represent?

• a.Acute metabolic acidosis
• b.Metabolic alkalosis
• c.Respiratory alkalosis✓
• d.Respiratory acidosis

An elevated pH with a low PaCO2 and a normal bicarbonate indicates respiratory alkalosis, often caused by hyperventilation.

A client with gastroenteritis has had severe diarrhea for two days. Which electrolyte imbalance is most likely?

• a.Hypokalemia✓
• b.Hyperkalemia
• c.Hypernatremia
• d.Hypercalcemia

Prolonged diarrhea causes significant potassium loss through the stool, leading to hypokalemia, which can produce weakness and cardiac dysrhythmias.

A nurse assesses a client in the compensatory stage of hypovolemic shock. Which finding is expected?

• a.Increased heart rate and cool, clammy skin✓
• b.Slow, deep respirations with a normal pulse
• c.Elevated blood pressure with warm, flushed skin
• d.Bradycardia with warm, dry, pink skin

In compensated shock, the body increases the heart rate and constricts peripheral vessels, producing tachycardia and cool, clammy skin as it attempts to maintain perfusion.

A client with pneumonia has a fever and thick secretions. Which intervention best promotes airway clearance?

• a.Restrict oral fluid intake to reduce sputum production
• b.Keep the client lying flat in bed to conserve energy
• c.Encourage fluids and provide chest physiotherapy as ordered✓
• d.Suppress the productive cough with medication so the client rests

Adequate hydration thins secretions and chest physiotherapy mobilizes them, promoting airway clearance. Restricting fluids and suppressing a productive cough would worsen secretion retention.

A nurse cares for a client with syndrome of inappropriate antidiuretic hormone (SIADH). Which finding is expected?

• a.Hyponatremia and fluid retention✓
• b.High serum osmolality
• c.Dehydration and excessive thirst
• d.Hypernatremia and increased urine output

SIADH causes excessive water retention, leading to dilutional hyponatremia, low serum osmolality, and concentrated urine. Fluid restriction is a key treatment.

A client with a history of gout has an elevated serum uric acid level. Which dietary teaching is appropriate?

• a.Avoid all dairy products because they raise uric acid
• b.Restrict water intake to reduce joint swelling
• c.Limit purine-rich foods and increase fluid intake✓
• d.Increase intake of organ meats and shellfish for protein

Limiting purine-rich foods such as organ meats and shellfish and increasing fluids helps lower uric acid and prevent gout attacks. Adequate hydration promotes uric acid excretion.

A nurse reviews a client's coagulation results. Which value indicates the client is at increased risk for bleeding?

• a.Hemoglobin of 14 g/dL
• b.INR of 5.0✓
• c.Platelet count of 250,000/microliter
• d.INR of 1.0

An INR of 5.0 is well above the therapeutic range and indicates a high bleeding risk. An INR of 1.0 and a normal platelet count reflect normal clotting ability.

A client with liver failure has a prolonged prothrombin time. Which nursing action is appropriate?

• a.Implement bleeding precautions and use a soft toothbrush✓
• b.Administer intramuscular injections freely for comfort medications
• c.Ignore minor bruising and gum bleeding as unimportant
• d.Encourage vigorous tooth brushing with a firm-bristled brush

A prolonged prothrombin time indicates impaired clotting, so bleeding precautions such as a soft toothbrush and avoiding unnecessary injections reduce the risk of hemorrhage.

A nurse is admitting a 78-year-old client who lives alone and was hospitalized after a hip fracture. At what point should the nurse begin discharge planning for this client?

• a.At admission, by identifying the client's likely need for post-hospital services✓
• b.On the day of discharge, after the provider writes the order and names a destination
• c.Once the client can walk the hallway with the walker without assistance
• d.When the client's insurance company approves a post-acute rehabilitation placement

The federal discharge planning requirement directs hospitals to identify, early in the stay, clients likely to suffer adverse consequences without adequate planning, so needs such as home health or extended care are worked out from admission onward. Waiting for the discharge order compresses planning into a few hours and is a common cause of failed transitions and readmission.

A nurse is transferring a client from the intensive care unit to a medical unit. The client has a patient-controlled analgesia pump and an indwelling urinary catheter. Which action by the transferring nurse best supports a safe transfer?

• a.Ask the client's daughter to explain the pump to the new nurse on arrival
• b.Give a face-to-face report to the receiving nurse and allow time for questions✓
• c.Send the printed transfer summary and let the receiving nurse read it later
• d.Chart a transfer note after the client has been moved to the new room

The Joint Commission's hand-off alert directs senders to communicate critical content both verbally, preferably face to face, and in writing, with ample opportunity for the receiver to ask questions, and warns against hand-offs made solely through paper or electronic communication. A written summary alone is the tempting choice because the information is technically transmitted, but nothing confirms the receiver got what was needed to manage the pump and catheter.

A nurse is using the ISBAR format to call a provider about a client whose urine output has fallen. Which statement belongs in the recommendation portion of the report?

• a.I am Dana Ruiz, the nurse caring for the client in room 412 tonight.
• b.The client has put out only 60 mL of urine over the past four hours.
• c.The client had an open cholecystectomy two days ago and has no allergies.
• d.I would like you to assess the client now and consider a fluid order.✓

In ISBAR the recommendation names what the nurse wants the provider to do, which is what converts a report into a request for action. The urine-output figure is the most tempting wrong choice because it is the reason for the call, but a measured finding is the situation being described, not the recommendation; the surgical history is background and the nurse's name is identification.

A unit uses the I-PASS mnemonic to structure shift hand-off. Which action carries out the final element, synthesis by the receiver?

• a.The departing nurse repeats the report a second time before leaving
• b.The oncoming nurse restates the plan and to-do list back to the sender✓
• c.The departing nurse files the completed hand-off form in the client record
• d.The oncoming nurse signs the printed hand-off sheet before rounds begin

I-PASS stands for illness severity, patient summary, action list, situation awareness and contingency plans, and synthesis by receiver, so the closing step belongs to the person receiving the client: summarizing back what was heard while the sender is still there to correct it. Signing the hand-off sheet records that a report happened but does not test whether the information arrived intact.

A client with two surgical drains and a pain pump is being transferred to a rehabilitation unit. The client's spouse says he will explain the drains and the pump to the new staff when they arrive. Which action should the nurse take?

• a.Report the drains and pump to the receiving nurse with the spouse present✓
• b.Tell the spouse that device information is not shared with family members
• c.Thank the spouse and let him relay the device details to the receiving staff
• d.Write the device details on a note for the spouse to hand to the new staff

The Joint Commission encourages sharing hand-off information with the client and family present, yet states plainly that clinicians should not rely on the client or family to communicate vital information about their care to the providers receiving the hand-off. Sending the details on a note carried by the spouse has the same flaw: the transfer of clinical responsibility still has to happen nurse to nurse.

At the end of the shift an RN transfers responsibility for a client's care to the oncoming RN. Under the NCSBN and ANA national guidelines, this transfer is best described as which of the following?

• a.Delegation of a nursing responsibility to a delegatee
• b.A hand-off between licensed health care providers✓
• c.Supervision of one licensed nurse by another
• d.An assignment of routine care by a nurse leader

The national delegation guidelines state that they do not apply to the transfer of responsibility for care of a patient between licensed health care providers, such as RN to RN, which is considered a hand-off. Delegation is the narrower act of transferring one specific nursing activity to a delegatee who would not routinely perform it, and it never moves the whole client.

An RN is caring for a stable client with type 2 diabetes. Which responsibility may the RN delegate to an experienced assistive personnel (AP) with documented competency?

• a.Assessing a new area of redness the client reports on the heel
• b.Deciding whether the ordered sliding-scale insulin dose should be given
• c.Teaching the client how and why to rotate the insulin injection sites
• d.Obtaining a capillary blood glucose reading and reporting the value✓

A point-of-care glucose measurement performed to protocol and reported back to the nurse is a task an AP can be trained and validated to do. Choosing the insulin decision is tempting because the AP produced the number, but the national guidelines state that the licensed nurse cannot delegate nursing judgment or any activity involving critical decision making; teaching and assessment are retained on the same grounds.

An RN delegated a morning bath to an AP for a client who was stable at the start of the shift. The AP returns and reports that the client became dizzy and confused while sitting up. Which action should the RN take first?

• a.Have the AP recheck the client's vital signs again in one hour
• b.Reassess the client and decide whether the delegation is still appropriate✓
• c.Reassign the bath to a different AP who has more years of experience
• d.Direct the AP to finish the bath while staying with the client the whole time

The right circumstance requires that the client's condition be stable, and the guidelines state that when the condition changes the delegatee must communicate it and the licensed nurse must reassess the situation and the appropriateness of the delegation. Sending the AP back to finish is tempting because the AP is already at the bedside, but new dizziness and confusion are findings only the RN can evaluate.

A charge nurse asks an AP to apply and monitor sequential compression devices. The AP says she has not used the devices before and does not feel able to do it safely. Which action is correct?

• a.The AP proceeds after another AP describes how the devices are used
• b.The AP proceeds, because the nurse keeps accountability for the client
• c.The AP declines, and the nurse applies the devices or arranges training✓
• d.The AP documents the concern in the record and applies the devices

The guidelines state that a delegatee who does not believe he or she has the competency to complete a delegated responsibility should not accept it, and that when delegation is not appropriate the delegating nurse should perform the activity herself. The accountability answer is tempting and half true: the nurse does retain accountability, which is a reason for her to act, not a reason for an untrained delegatee to proceed.

An RN is distributing work on a unit staffed with RNs, LPN/VNs, and AP. Which responsibility is appropriate to assign to the LPN/VN?

• a.Writing the outcome goals in a newly admitted client's care plan
• b.Performing the admission assessment on a client arriving from surgery
• c.Reinforcing low-sodium diet instructions the RN taught yesterday✓
• d.Evaluating whether teaching about a new diagnosis was effective

Reinforcing instruction the RN has already delivered sits inside the LPN/VN role, while the initial assessment, development of the plan of care, and evaluation of teaching are clinical-judgment steps the RN retains. LPN/VN scope varies by state, so the reliable way to answer these items is to look for the retained RN core rather than to reason from a particular state's task list.

A state nurse practice act permits AP to remove peripheral IV catheters, but the hospital's written policy states that only licensed nurses may remove them. Which statement about the nurse's obligation is correct?

• a.The nurse follows the hospital policy, which may be more restrictive✓
• b.The nurse may delegate the removal once the AP has been checked off by an educator
• c.The nurse follows the practice act, which overrides the local policy
• d.The nurse may delegate the removal with the charge nurse's approval

The national guidelines require employer delegation policies to be consistent with the practice act and note that institution or employer policies can be more restrictive, but not less restrictive, than the act. A permissive practice act sets an outer boundary rather than a permission slip, and no individual nurse or charge nurse can waive a facility policy that withholds the task.

A nurse is giving discharge medication instructions to a client with limited English proficiency. The client's 15-year-old grandson offers to interpret. Which action should the nurse take?

• a.Ask a bilingual assistive personnel on the unit to interpret the instructions
• b.Give written instructions in the client's language and omit the verbal teaching
• c.Obtain a qualified interpreter through the hospital at no cost to the client✓
• d.Allow the grandson to interpret, since the client trusts him to be accurate

Federal rules require covered health programs to provide language assistance free of charge, accurately and in a timely way, and prohibit relying on a minor child to interpret except briefly in an emergency while a qualified interpreter is found. Asking bilingual staff is the closest wrong answer, because a staff member who speaks the language is not automatically qualified as an interpreter.

A client recovering from a stroke tells the nurse she wants to return to her own home with help, while her adult children have already toured a skilled nursing facility. Which action by the nurse best advocates for the client?

• a.Explain to the client that her children have picked the safer care setting for her
• b.Ask the children to spend more time persuading the client to agree to the plan
• c.Document the client's wish in the record and continue with the facility placement
• d.Bring the client's stated goal to the discharge planning team for evaluation✓

The discharge planning regulation requires a process that focuses on the client's own goals and treatment preferences and that treats the client and caregivers as active partners, so advocacy means getting the stated goal formally evaluated, including whether home health could meet the need. Documenting the wish and proceeding anyway is the near-miss answer: it creates a record without giving the client any part in her own plan.

Four clients on a surgical unit press their call lights at the same time. Which client should the nurse go to first?

• a.A client 2 days after abdominal surgery who is asking for an antiemetic
• b.A client 1 day after knee replacement rating incisional pain 6 of 10
• c.A client 3 days after bowel resection who has not yet passed any flatus
• d.A client 4 hours after thyroidectomy with a high-pitched inspiratory sound✓

A high-pitched inspiratory sound is stridor, described by MedlinePlus as caused by a blockage in the throat or larynx and treated as an emergency; after thyroidectomy it can mean the airway is narrowing from swelling or a hematoma, so it outranks pain, nausea, and delayed flatus. The other three findings need attention during the shift but none of them is an airway problem.

A nurse begins the shift with four clients. Which client is appropriate for the nurse to see last?

• a.A client reporting sudden pain and tightness in one calf while resting
• b.A client whose oxygen saturation fell from 96% to 89% on 2 L of oxygen
• c.A client with new confusion who was fully oriented at the previous shift
• d.A client waiting on routine morning labs before a planned discharge✓

Waiting on routine results before a planned discharge is the only situation with no change in the client's condition, while altered mental status and an oxygen saturation below 90% are both standard rapid-response calling criteria and new unilateral calf pain may signal a clot. Deciding who can wait uses the same acuity judgment as deciding who is first, applied from the other end of the list.

Two days after an ischemic stroke, a client coughs after sips of water and has a wet, gurgly voice at the end of the meal. Which action should the nurse take?

• a.Thicken the client's liquids and finish the rest of the meal at the bedside
• b.Have the assistive personnel feed the client slowly while sitting upright
• c.Record the finding and watch the client closely again at the next meal
• d.Stop oral intake and request an order for a swallowing evaluation✓

Coughing during or after drinking and a wet or gurgly voice are signs ASHA lists as warranting a swallowing assessment by a speech-language pathologist, and both that referral and any diet change need a provider order. Thickening the liquids is the most tempting wrong action because it feels protective, but it is a treatment decision outside the nurse's independent scope and ASHA notes thickened fluids may not eliminate aspiration risk.

A client with end-stage kidney disease is ready for discharge but has no stable housing and no way to get to outpatient dialysis three times a week. Which referral should the nurse initiate?

• a.Physical therapist, to build the endurance needed for the trip to dialysis
• b.Dietitian, to build a renal meal plan the client can follow at a shelter
• c.Social worker, to connect the client with housing and transport resources✓
• d.Occupational therapist, to adapt daily routines around the dialysis schedule

Social workers research, refer to, and advocate for community resources such as housing and health care, and health care social workers specifically help people move from the hospital back into their communities. The other three consults address real needs, but none of them removes the housing and transportation barrier that will otherwise stop the dialysis from happening at all.

A home health nurse determines that a client who is unsteady on stairs would benefit from gait training and a bedside commode. Which action should the nurse take next?

• a.Tell the family to buy a commode and to supervise the stairs at home
• b.Ask the home health aide to walk the client on the stairs each visit
• c.Add gait training to the plan of care and begin the exercises today
• d.Contact the provider to obtain orders for therapy and the equipment✓

Identifying the need is nursing judgment, but home health services are delivered under a plan of care established and signed by a physician or allowed practitioner that must specify the types of services, supplies, and equipment required, so the orders are what turn the assessment into delivered care. Starting gait training independently substitutes the nurse for the discipline whose scope covers it.

A care plan goal states that a client will ambulate 50 feet with a walker by postoperative day 3. On day 3 the client has walked only to the bathroom door. Which action reflects the evaluation step of the nursing process?

• a.Delete the mobility goal and document that the client declined it
• b.Record the goal as met, because the client did get out of bed today
• c.Identify what limited progress and revise the goal and interventions✓
• d.Keep the plan unchanged and re-evaluate the same goal on postoperative day 5

Evaluation means reassessing whether the desired outcome was achieved and then adapting the plan of care on the new data, so an unmet goal triggers revision of the goal and the interventions behind it. Recording the goal as met because the client moved at all is the tempting error, since it changes the documentation instead of the care.

At 0700 a nurse has these tasks: a client due in the operating room at 0730 who has not voided, an 0800 insulin dose, a 0900 dressing change, and a routine bed bath. Which task should the nurse do first?

• a.Complete the bed bath so that the rest of the morning stays clear
• b.Draw up and give the scheduled 0800 dose of the client's insulin
• c.Change the surgical dressing that is scheduled for 0900 this morning
• d.Assist the pre-operative client to void before transport at 0730✓

Organizing a workload means working outward from the deadlines that other departments own: the transport time is set by the operating room and cannot be moved, while the insulin and the dressing change have later windows and the bath has none. Doing the bath first to clear the morning is the classic error, because it spends the only uncommitted block on the only task with no deadline.

A nurse has six clients and two new admissions arriving within the hour, and one AP is available. Which approach best organizes the workload?

• a.Delegate the admission assessments so the nurse can finish the medication pass on time
• b.Delegate the tasks and check the results at the end of the shift report
• c.Delegate vital signs and hygiene for the stable clients, with reporting limits✓
• d.Keep every task, because explaining the work takes longer than doing it alone

Handing routine care for stable clients to the AP with specific values to report back frees the RN for the assessments and admissions only she can do, and it satisfies the right directions and communication element of delegation. Delegating the admission assessments fails the right task, and delegating without following up until report fails the right supervision and evaluation.

Over 20 minutes a client's respiratory rate rises from 18 to 30 and the client becomes confused. The nurse has paged the provider twice with no response. Which action should the nurse take?

• a.Raise the oxygen flow rate and reassess the client in 30 minutes
• b.Page the provider a third time and recheck the client in 15 minutes
• c.Ask the charge nurse to move the client closer to the nurses station
• d.Activate the rapid response team for the client's change in condition✓

Rapid response systems exist to bring critical care skill to a deteriorating client before an arrest, and their calling criteria include altered mental status, an abnormal respiratory rate, and a staff member's significant concern about the client, with no provider authorization required to call. Paging again while the client worsens is exactly the failure-to-rescue pattern these teams were built to interrupt.

A medical-surgical nurse is floated to an oncology unit and assigned to give an intravenous chemotherapy infusion she has not been trained to administer. Which action should the nurse take?

• a.Decline the entire float assignment and return to her home unit
• b.Give the infusion while an oncology nurse talks her through each step
• c.Tell the charge nurse she is not trained and ask for a different client✓
• d.Read the unit protocol and give the infusion at the scheduled time

A delegatee, including a licensed nurse, must accept only responsibilities she is trained and competent to carry out and must tell nursing leadership when she has not had adequate training, which lets the charge nurse move that client and give her work within her competence. Walking off the float assignment is the tempting overcorrection: recognizing a limitation means renegotiating the task, not leaving a short unit shorter.

A client with left-sided weakness after a stroke walks safely with a cane but cannot dress himself or manage utensils. Which team member should the nurse consult?

• a.Occupational therapist, for retraining in dressing and eating tasks✓
• b.Speech-language pathologist, for retraining in swallowing and speech
• c.Respiratory therapist, for retraining in breathing and airway clearance
• d.Physical therapist, for retraining in walking and stair-climbing tasks

Occupational therapists help clients relearn daily living tasks, including teaching a person who has had a stroke how to get dressed, and they recommend eating aids and other adaptive equipment. Physical therapy is the tempting pick after a stroke, but this client's gait is already safe with a cane and the deficit is in self-care activities.

A client with COPD has thick retained secretions and a weak cough, and the provider has ordered chest physiotherapy and a change in oxygen delivery. Which team member should the nurse collaborate with to carry out these orders?

• a.Registered dietitian, who plans the intake needed to support breathing
• b.Respiratory therapist, who gives chest physiotherapy and sets up oxygen✓
• c.Physical therapist, who gives endurance training and gait retraining
• d.Clinical social worker, who arranges home equipment and follow-up care

Respiratory therapists perform chest physiotherapy to move mucus out of the lungs and set up and monitor the equipment that delivers the correct amount of oxygen at the correct rate, which is precisely what these two orders require. The other consults are reasonable later in the stay, but none of them executes the ordered airway clearance.

A client scheduled for a laparoscopic cholecystectomy in 45 minutes tells the nurse, “I signed the paper, but I still don’t know what they plan to remove or what could go wrong.” The preoperative midazolam has not yet been given. Which action should the nurse take?

• a.Ask the client’s spouse to explain the procedure the surgeon described earlier
• b.Describe the procedure and its usual risks to the client and then proceed
• c.Give the midazolam as ordered and reinforce the teaching once the client is calm
• d.Notify the surgeon to discuss the procedure before sedation is given✓

The provider who will perform the procedure is responsible for explaining its nature, risks, benefits, and alternatives; the nurse verifies that the client understood and alerts the surgeon when that understanding is missing. Explaining the procedure in the surgeon’s place does not create valid informed consent.

A nurse is asked to witness a surgical consent signature 10 minutes after intravenous midazolam was given to the client. Which action should the nurse take?

• a.Ask a second nurse to co-sign the consent form to confirm the client was alert
• b.Decline to witness and tell the surgeon that consent must be obtained first✓
• c.Witness the signature and note in the record that midazolam was given first
• d.Witness the signature after the client repeats the name of the planned procedure

Consent signed while a client is under a sedating drug is not valid, because the client can no longer demonstrate understanding of what is being agreed to; the discussion and signature belong before sedation. Documenting the sedation or adding a second signature does not restore the client’s capacity to consent.

An unresponsive adult is brought to the emergency department after a motor vehicle crash and needs immediate surgery for internal bleeding. No family member or surrogate decision maker can be located. Which statement should guide the nurse’s action?

• a.Emergency treatment may proceed under the emergency exception to informed consent✓
• b.Surgery must be delayed until a family member is located and gives permission
• c.A court order is required before any surgical procedure may be performed
• d.Two staff members may sign the consent form on behalf of the unresponsive client

Informed consent may be waived when an emergency leaves no time to obtain it, the client cannot communicate, and no surrogate is available, because a reasonable person would be presumed to want life-saving care. Delaying hemorrhage surgery to locate a family member who cannot be found would cause the harm consent rules exist to prevent.

A 17-year-old client who is married and living independently presents alone for treatment of a fractured wrist. The client’s parents live in another state. Which action should the nurse take regarding consent?

• a.Treat the injury under implied consent because the client arrived alone
• b.Have the client sign the consent, because a married minor is emancipated✓
• c.Telephone a parent in the other state for permission before treating
• d.Ask the client’s spouse to sign the consent form for the wrist treatment

A minor who is legally emancipated — for example through marriage, military service, or a court order — gives their own informed consent for care. Implied consent covers emergencies in which the client cannot communicate a decision, which does not apply to an alert client with a wrist fracture.

A nurse is teaching a client about advance directives. Which client statement indicates that the teaching was effective?

• a.“An advance directive is required before the hospital can admit me for care.”
• b.“A durable power of attorney for health care names who speaks for me.”✓
• c.“My advance directive takes effect the moment I sign it in front of a notary.”
• d.“A living will lets my daughter choose my treatments while I am still alert.”

A durable power of attorney for health care designates a health care proxy to speak for the client, while a living will records treatment preferences without naming a decision maker. Advance directives take effect only when the client can no longer make or communicate decisions, and a facility may not require one as a condition of care.