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Questions 148

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Question 1 of 5

The nurse is caring for a 42-year-old client who has a do not resuscitate (DNR) order on the chart. The client tells the nurse, 'I've changed my mind about the DNR. I would like to cancel that and be given whatever care is needed to keep me alive.' Which response by the nurse is correct?

Correct Answer: A

Rationale: A DNR can be revoked by the client at any time. Notifying the provider ensures the change is documented and followed.

Question 2 of 5

The nurse is delegating tasks to an experienced, unlicensed assistive personnel (UAP). Which of the following clients should the nurse delegate to the UAP?

Correct Answer: C

Rationale: Ambulating a client is within a UAP’s scope, requiring minimal clinical judgment, unlike wound care, tracheostomy care, or pain assessment.

Question 3 of 5

If the nurse is unable to elicit the deep tendon reflexes of the patella, the nurse should ask the client to:

Correct Answer: A

Rationale: Pulling against the palms enhances reflex response by increasing muscle tone, aiding in eliciting the patellar reflex.

Question 4 of 5

A nurse on the orthopedics floor is asked by another nurse to witness her waste 1 mg of morphine. The nurse draws the full 2 mg dose of morphine into the syringe and tells the first nurse, 'This client does not get enough pain relief with 1 mg of morphine, so I just go ahead and give 2 mg to keep him comfortable because the doctor won't change the dose.' Which is the correct action by the first nurse?

Correct Answer: B

Rationale: Administering an unordered dose is a medication error and potential diversion. Refusing to sign and reporting ensures patient safety and accountability.

Question 5 of 5

The nurse is caring for a client admitted with congestive heart failure. Which finding would the nurse expect if the failure was on the right side of the heart?

Correct Answer: A

Rationale: Right-sided heart failure causes systemic venous congestion, leading to jugular vein distention, a hallmark sign of impaired right heart function.

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