a client is having an abortion in a womens clinic and the nurse caring for the client does not think the reasoning is appropriate the nurse asks are y
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Nursing Elites

NCLEX-PN

Nclex PN Questions and Answers

1. A client is having an abortion in a women's clinic, and the nurse caring for the client does not think the reasoning is appropriate. The nurse asks, "Are you sure you want to do this? It can't be undone. Have you read about your other options? Adoption is always a good choice."? The client states she understands all options and is comfortable with her choice. The nurse nods and leaves the room to discuss the procedure with the physician. Which client right did the nurse violate with her actions?

Correct answer: A

Rationale: A client has the right to make decisions about their healthcare without interference from healthcare team members. In this scenario, the nurse violated the client's right to make personal health decisions without interference by trying to influence the client's decision-making and healthcare choice in the direction of not having an abortion. It is essential for healthcare providers to respect patients' autonomy and decisions, regardless of personal beliefs. Choices B, C, and D are incorrect because the primary violation in this situation is related to the client's right to make their own healthcare decisions without interference.

2. Under what circumstances can an individual receive medical care without giving informed consent?

Correct answer: B

Rationale: An individual may receive medical care without giving informed consent in an emergency, life-or-death situation. This exception allows healthcare providers to provide immediate treatment to save a person's life or prevent serious harm when time is of the essence. Choices A, C, and D are incorrect because in all other situations, informed consent is required. The durable power of attorney for health care should be involved if available, the physician should have a discussion with the client in non-life-threatening situations, and in cases where clients are unable to speak for themselves, their designated representative or responsible party should be involved in the consent process.

3. A graduate nurse hired to work in a medical unit of a hospital is attending an orientation session. The nurse educator, discussing care maps, asks the graduate nurse whether she understands how a care map is used. Which response indicates understanding?

Correct answer: A

Rationale: The correct answer is A. A care map, also known as a critical pathway, outlines the day-to-day expected outcomes of care and the outcomes anticipated at discharge or the end of a treatment phase. It includes clinical assessments, treatments, dietary interventions, activity therapies, client education, and discharge planning. While it may identify nursing diagnoses, a care map is developed by all disciplines caring for the client type and is used by the interdisciplinary team, not just the nurse alone. Choice B is incorrect because a care map is not solely for the nurse but for the entire interdisciplinary team. Choice C is incorrect as care maps are individualized plans developed by the interdisciplinary team, not just by a nurse. Choice D is incorrect as a care map is not solely about nursing diagnoses but encompasses a comprehensive plan of care.

4. A client with a pleural drainage system to suction has gentle bubbling of the water seal. What should the nurse do?

Correct answer: D

Rationale: Gentle bubbling is a normal finding for a client with a pleural drainage system to suction, so it simply needs to be documented for monitoring purposes. If the bubbling becomes vigorous, it could indicate a leak, which would then require further investigation by the nurse. Therefore, the correct action at this point is to document the finding. Notifying the physician is not necessary for gentle bubbling as it is expected. Clamping the chest tube or replacing the system is inappropriate and could potentially harm the client as there is no indication for such actions based on the scenario provided.

5. Priorities designated as intermediate by the nurse are:

Correct answer: A

Rationale: Priorities designated as intermediate by the nurse are those that are not urgent but still important, such as the nonemergency, non-life-threatening needs of the client. They do not impact the client's immediate physiological status but require attention. Intermediate priorities may need the skill level of an RN for completion and may have specific time requirements. Choices B, C, and D are incorrect because the priority being intermediate doesn't mean it can be delegated, done at a specific time, or done at any time; it simply indicates a non-urgent but necessary task for the client's well-being.

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