Nclex PN Questions and Answers - Nurselytic

Correct Answer: C

Rationale: The correct action for the nurse to take first is to inform the healthcare provider that removal of a chest tube is not a nursing procedure. Actual removal of a chest tube is the duty of a healthcare provider. If the healthcare provider insists that the nurse remove the tube, the nurse must contact the nursing supervisor. Some agencies' policies and procedures may permit an advanced practice nurse to remove a chest tube, but there is no information in the question to indicate that the nurse is an advanced practice nurse.
Choice A is incorrect because the nurse should not proceed with removing the chest tube without proper authorization.
Choice B is incorrect as calling the nursing supervisor should come after clarifying with the healthcare provider.
Choice D is incorrect as the nurse should not begin the process of removing the chest tube without proper guidance and authorization.

Correct Answer: C

Rationale: Ethics in nursing refers to the moral principles that govern a nurse's behavior and decision-making. It involves being able to differentiate right from wrong, making choices that are morally sound, and upholding integrity in patient care. While advocating for the client (choice
A) is an important aspect of nursing care, it does not fully encompass the broad concept of ethics. Knowing your scope of practice (choice
B) is essential for safe and competent care but is not a comprehensive definition of ethics. Being willing to report violations (choice
D) is part of ethical practice, but it is not the core definition of ethics in nursing.

Correct Answer: A

Rationale: The four categories related to client care plans are diagnosis, intervention, outcome, and evaluation. Privacy is not typically considered a distinct category in client care plans, as it is more of a fundamental aspect that underlies all care provided to clients.

Choices B, C, and D are directly related to the components of client care plans, making them incorrect answers in this context.

Correct Answer: C

Rationale: The correct hierarchy order from least to highest authority in the nursing team is LPN (Licensed Practical Nurse), staff nurse, charge nurse, and nurse manager. LPNs have the least authority, followed by staff nurses who are supervised by charge nurses. Nurse managers oversee the charge nurses, making them the highest authority in this hierarchy.
Therefore, choices A, B, and D are incorrect as they do not follow the correct order of authority within the nursing team.

Correct Answer: C

Rationale: When a client requests a DNR order, the nurse should contact the healthcare provider so that the provider may discuss the request with the client. A DNR order should be written, not verbal, following agency and state guidelines.
Therefore, the correct answer is that the DNR request should be discussed with the healthcare provider, who will write the order. Option A is incorrect as oral consent is not sufficient for a DNR order. Option B is incorrect because the client, not the family, has the authority to request a DNR order. Option D is incorrect because the healthcare provider discusses the request with the client but does not make the final decision.