Correct Answer: D

Rationale: The correct answer is D because explaining the steps of a surgical procedure to a client is considered unprofessional behavior by a nurse. Nurses are not qualified to provide medical explanations or advice, as this falls under the responsibility of the healthcare provider performing the procedure. It is essential for nurses to maintain their professional boundaries and roles in healthcare settings.


Choice A is incorrect because confirming a client's competency is a crucial part of ensuring informed consent.
Choice B is incorrect as verifying voluntary consent is a necessary ethical practice.
Choice C is incorrect as witnessing a client's consent is part of the process.

Correct Answer: D

Rationale: Interpreting data is part of the analysis step in critical thinking. Analysis involves breaking down information, examining its components, and drawing conclusions. It is crucial in making informed decisions based on evidence. Intuition (
A) is a gut feeling without explicit reasoning. Questioning (
B) involves seeking information rather than interpreting it. Creativity (
C) involves generating new ideas, not necessarily analyzing existing data.
Therefore, D is the correct answer as it directly relates to interpreting data in the critical thinking process.

Correct Answer: C

Rationale: The correct answer is C: Assigning a new graduate nurse to perform a wet-to-dry dressing change. This assignment is an example of overdelegation because a wet-to-dry dressing change requires specialized knowledge and skills that a new graduate nurse may not possess. Wet-to-dry dressing changes involve assessing wound conditions, applying dressings correctly, and monitoring for signs of infection or complications. A new graduate nurse may not have had enough experience or training to perform this task safely and effectively.


Choice A is not overdelegation because glucometer monitoring is a routine task that can be safely delegated to a competent AP.
Choice B is not overdelegation as ambulating clients is a task that can be shared among multiple personnel to ensure client safety.
Choice D is not overdelegation as performing a central line dressing change requires advanced skills that a competent RN would possess.

Correct Answer: A,B,D

Rationale: Subjective data refers to information provided by the client that cannot be objectively measured or observed. In this question, choices A, B, and D are subjective data because they involve the client's personal experiences and feelings that are reported to the nurse.
Choice A ("Client reports dull, aching pain in lower right calf") is subjective as pain is a personal sensation.
Choice B ("Client reports nausea following administration of pain medication") is subjective as nausea is a symptom that the client feels.
Choice D ("Client reports the rash on their back is itchy") is subjective as itchiness is a personal sensation. On the other hand, choices C and E involve objective data that can be measured or observed.
Choice C ("Client's oral temperature is 38.4°C (101.2°F)") is objective as it is a measurable temperature reading.
Choice E ("Client has a vesicular rash on their upper back") is objective as it describes a visible skin condition.
Therefore, choices A, B,

Correct Answer: A

Rationale: The correct answer is A: Client goals. The IDEAL toolkit focuses on discussing five key areas with the client during discharge planning. Client goals are crucial as they help tailor the plan to the client's needs and preferences, promoting client-centered care. Discussing client goals ensures that the plan aligns with the client's desired outcomes, increasing compliance and satisfaction. The other choices are incorrect because the toolkit does not specifically emphasize them as key areas. Discharge process, family member preferences, and test results are important aspects but do not fall under the core areas identified by the IDEAL toolkit for client discussions.