Nclex PN Questions and Answers - Nurselytic

Correct Answer: D

Rationale: Nurses should address any concerns regarding a client's health, even if they are not directly related to the reason for hospitalization. In this case, the nurse noticing the client's poor gait and balance should communicate these concerns to the attending physician. The correct course of action is to request a referral to physical therapy, as this specialized intervention can help address the client's issues effectively. Adding gait/balance training to the care plan without professional assessment and intervention may not be appropriate. Doing nothing is not in line with providing comprehensive care, and referring the client to the hospital gym is not as effective as a referral to physical therapy for addressing gait and balance issues.

Correct Answer: B

Rationale: The correct answer is B: Nonmaleficence. Nonmaleficence is the principle of avoiding harm. In healthcare ethics, practitioners aim not only to do good but also to ensure they do no harm. In this scenario, the healthcare team is discussing treatment options with the intention of inflicting the least harm on the client.
Choice A, Fidelity, refers to keeping promises made to clients, families, and healthcare professionals.
Choice C, Autonomy, pertains to respecting a person's independence and right to make decisions.
Choice D, Justice, involves fairness, equity, and the fair allocation of resources, such as healthcare services.

Correct Answer: D

Rationale: Process standards define the actions and behaviors required by staff to provide care on a med-surg unit. A procedure for changing IV tubing is a critical psychomotor skill necessary for safe and effective patient care in this setting.
Choice B, a policy for staffing, pertains more to organizational management rather than specific care processes on the unit.
Choice C, the job description of the CEO, delineates the responsibilities of the organization's top executive and is not a process standard for frontline staff.
Choice D, a procedure for checking waveforms on a client with an intra-aortic balloon pump, is more specific to a cardiac care unit and not typically performed on a med-surg unit.

Correct Answer: C

Rationale: A client's medical condition is confidential and should never be discussed with anyone other than the client and the client's healthcare provider.
Therefore, the nurse must tell the unit secretary that the client's condition is not to be discussed.

Choices A and B confirm the client's disease, which is inappropriate as it breaches patient confidentiality.
Choice D promotes further discussion of the client's condition, which is also inappropriate. The correct response is to firmly state, 'We can't discuss a client's medical condition,' to uphold patient privacy and confidentiality.

Correct Answer: A

Rationale: The correct statement is that the nurse should ensure the client is educated on their discharge instructions. This is crucial to promote continuity of care and prevent adverse events. The responsibility of educating the client falls on the nurse, not assuming stability without a follow-up visit. While the physician may prescribe medications, it is the nurse's responsibility to ensure the client has them before discharge. Instructing the client to bring up questions at a follow-up appointment is not ideal; all questions should be addressed before discharge to ensure the client's understanding and compliance.