Nursing Elites

1. A client is reviewing a medical record for advance directives. Which client statement indicates an understanding of the teaching?

• A. I don't need a living will because my family will make decisions.
• B. My living will takes effect only if I lose consciousness.
• C. My family will decide when to follow my living will.
• D. I can change my living will at any time.

Correct answer: D

Rationale: The correct answer is D because clients can change their living will at any time as long as they are mentally competent. Choice A is incorrect because relying solely on family to make decisions may not align with the client's wishes. Choice B is incorrect because a living will can address various situations, not just loss of consciousness. Choice C is incorrect because the client should be the primary decision-maker regarding their living will, not the family.

2. A client signed an informed consent form for surgery but has expressed doubts about the need for surgery. What should the nurse say?

• A. Reassure the client of the surgeon's skill
• B. The surgeon will answer your questions before surgery
• C. Tell the client surgery is necessary
• D. Encourage the client to seek a second opinion

Correct answer: B

Rationale: The correct answer is B because the surgeon should address the client's doubts before surgery. Informed consent requires that the client fully understands the procedure. Choice A is incorrect because reassuring the client of the surgeon's skill does not address the client's doubts about the need for surgery. Choice C is incorrect because telling the client surgery is necessary may not address their concerns and could violate the principle of autonomy. Choice D is incorrect as the immediate concern is addressing the client's doubts before surgery, not necessarily seeking a second opinion.

3. A nurse is assessing a client who has received intermittent enteral feedings. What finding indicates the client is tolerating the feeding?

• A. Nausea and vomiting
• B. Normal bowel sounds
• C. Weight gain
• D. Decreased abdominal distention

Correct answer: D

Rationale: The correct answer is D: Decreased abdominal distention. This finding indicates that the client is tolerating the feeding well without experiencing bloating or discomfort. Nausea and vomiting (choice A) are symptoms of intolerance to enteral feedings. Normal bowel sounds (choice B) are a good sign but do not directly indicate tolerance to the feeding. Weight gain (choice C) may occur due to factors other than enteral feedings.

4. When reviewing the health history of an older adult with a hip fracture, what should a nurse identify as a risk factor for developing pressure injuries?

• A. Malnutrition
• B. Poor hygiene
• C. Urinary incontinence
• D. Immobility

Correct answer: C

Rationale: Urinary incontinence is a risk factor for skin breakdown, which can lead to the development of pressure injuries. While malnutrition, poor hygiene, and immobility are important considerations in overall patient care, they are not specifically identified as significant risk factors for pressure injuries in this scenario.

5. A charge nurse discovers that a nurse did not notify the provider that a client's condition had changed. The charge nurse should identify that the nurse is accountable for which of the following torts?

• A. Negligence
• B. Assault
• C. Battery
• D. Defamation

Correct answer: A

Rationale: The correct answer is A: Negligence. Negligence in nursing occurs when a healthcare provider fails to take appropriate action that a reasonably prudent provider would take in a similar situation, such as not notifying the provider of changes in a client's condition. In this scenario, the nurse's failure to inform the provider of the client's changed condition constitutes negligence. Choices B, C, and D are incorrect. Assault involves the intentional threat of bodily harm to another person, battery is the intentional harmful or offensive touching of another person without their consent, and defamation is the act of making false statements about someone to a third party that harms that person's reputation.

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