Saunders Comprehensive Review for NCLEX-PN - Chapter 6

15. The nurse enters a client's room and notes that the client's lawyer is present and that the client is prepar- ing a living will. The living will requires that the cli- ent's signature be witnessed, and the client asks the nurse to witness the signature. Which is the appro- priate nursing action? 1. Decline to sign the will. 2. Sign the will as a witness to the signature only. 3. Call the hospital lawyer before signing the will. 4. Sign the will, clearly identifying credentials and employment agency.

1. Decline to sign the will.

12. The licensed practical nurse (LPN) enters a client's room and finds the client lying on the bathroom floor. The LPN calls the registered nurse, who checks the client thoroughly and then assists the cli- ent back into bed. The LPN completes an incident report, and the nursing supervisor and primary are notified of the health care provider (PHCP) incident. Which is the next nursing action regard- ing the incident? 1. Place the incident report in the client's chart. 2. Make a copy of the incident report for the PHCP 3. Document a complete entry in the client's record concerning the incident. 4. Document in the client's record that an incident report has been completed

3. Document a complete entry in the client's record concerning the incident.

18. A client has died, and the nurse asks a family mem- ber about the funeral arrangements. The family member refuses to discuss the issue. Which is the appropriate nursing action? 1. Show acceptance of feelings. 2. Provide information needed for decision making. 3. Suggest a referral to a mental health professional. 4. Remain with the family member without discussing funeral arrangements.

4. Remain with the family member without discussing funeral arrangements.

11. Which identifies accurate nursing documentation notations? Select all that apply. 1. The client slept through the night. 2. Abdominal wound dressing is dry and intact without drainage. 3. The client seemed angry when awakened for vital sign measurement. 4. The client appears to become anxious when it is time for respiratory treatments. 5. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.

1. The client slept through the night. 2. Abdominal wound dressing is dry and intact without drainage. 5. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.

16. The nurse finds the client lying on the floor. The nurse calls the registered nurse, who checks the cli- ent and then calls the nursing supervisor and the primary health care provider to inform them of the mary occurrence. The nurse completes the incident report for which purpose? 1. Providing clients with necessary stabilizing treatments 2. A method of promoting quality care and risk management 3. Determining the effectiveness of interventions in relation to outcomes 4. The appropriate method of reporting to local, state, and federal agencies

2. A method of promoting quality care and risk management

17. The nurse observes that a client received pain med- ication 1 hour ago from another nurse, but the client still has severe pain. The nurse has previously observed this same occurrence several times. Based on the nurse practice act, the observing nurse should plan to take which action? 1. Report the information to the police. 2. Call the impaired nurse organization. 3. Talk with the nurse who gave the medication. 4. Report the information to a nursing supervisor.

4. Report the information to a nursing supervisor.

14. The nurse arrives at work and is told to report (float) to the pediatric unit for the day because the unit is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the pediatric unit. Which is the appropriate nursing action? 1. Call the hospital lawyer. 2. Call the nursing supervisor. 3. Refuse to float to the pediatric unit. 4. Report to the pediatric unit and identify tasks that can be safely performed.

4. Report to the pediatric unit and identify tasks that can be safely performed.

13. An unconscious client, bleeding profusely, is brought to the emergency department after a serious accident. Surgery is required immediately to save the client's life. With regard to informed consent for the surgical procedure, which is the best action? 1. Call the nursing supervisor to initiate a court order for the surgical procedure. 2. Try calling the client's spouse to obtain telephone consent before the surgical procedure. 3. Ask the friend who accompanied the client to the emergency department to sign the consent form. 4. Transport the client to the operating department immediately without obtaining an informed consent.

4. Transport the client to the operating department immediately without obtaining an informed consent.