NCLEX-PN
Nclex PN Questions and Answers Questions
Extract:
Question 1 of 5
The nurse in the emergency room is admitting a client who has sustained a gunshot wound and will require immediate surgery. The client is unconscious and by themselves. Which of the following actions is most appropriate?
Correct Answer: D
Rationale: In emergency situations where a client is unconscious and requires immediate surgery to save their life, the priority is to proceed with necessary interventions without delay to ensure the best possible outcome. Obtaining informed consent is essential in healthcare, but in situations where a delay in treatment can be life-threatening, healthcare providers are ethically and legally permitted to proceed with treatment without consent. Attempting to stabilize the client until conscious enough to provide consent or trying to locate family members for consent would cause a dangerous delay in critical care.
Therefore, the most appropriate action in this scenario is to transport the unconscious client to the operating room for immediate surgery.
Question 2 of 5
A client with cancer is transported to the radiology department for a bone scan to determine whether the cancer has metastasized to bone. While the client is in the radiology department, the client's wife arrives for a visit and asks what test is being performed on the client. What should the nurse tell the wife?
Correct Answer: D
Rationale: In healthcare, confidentiality is crucial. Without the client's consent, nurses cannot disclose confidential information to anyone else, even to family members.
Therefore, the appropriate response is to inform the client's wife that she will have to discuss the test with the client directly. It is not appropriate to disclose sensitive medical information without the client's permission. Offering the wife to read the medical record is a violation of privacy and confidentiality. Indicating that the radiology department is unclear about the prescribed test is inaccurate and does not uphold confidentiality. Moreover, it is not the responsibility of another department to disclose medical information; it is the duty of the healthcare provider and the client to discuss such matters.
Question 3 of 5
A nursing student is assigned to care for a client who requires a total bed bath. When the student explains to the client that she is going to gather supplies to administer the bath, the client states, 'I don't want a bath. I've been up all night, and I'm clean enough.' The student reports the client's refusal to the nurse. Which action by the nurse is appropriate?
Correct Answer: B
Rationale: The client has the right to refuse a treatment or procedure, and if the client does refuse, the nurse must respect the client's decision.
Therefore, the nurse would allow the client to rest. Persuading the client to have a bath and giving the bath anyway are both inappropriate as they violate the client's rights. Informing the health care provider of the refusal of care can be discussed with the client if needed, but the immediate action should be to respect the client's wishes and allow them to rest.
Question 4 of 5
The nurse in the emergency room is admitting a client who has sustained a gunshot wound and will require immediate surgery. The client is unconscious and by themselves. Which of the following actions is most appropriate?
Correct Answer: D
Rationale: In emergency situations where a client is unconscious and requires immediate surgery to save their life, the priority is to proceed with necessary interventions without delay to ensure the best possible outcome. Obtaining informed consent is essential in healthcare, but in situations where a delay in treatment can be life-threatening, healthcare providers are ethically and legally permitted to proceed with treatment without consent. Attempting to stabilize the client until conscious enough to provide consent or trying to locate family members for consent would cause a dangerous delay in critical care.
Therefore, the most appropriate action in this scenario is to transport the unconscious client to the operating room for immediate surgery.
Question 5 of 5
During an emergency procedure, is the surgical timeout a requirement?
Correct Answer: A
Rationale: During an emergency procedure, the surgical timeout should be performed unless doing so would cause a delay leading to injury or death. This is because the primary goal during an emergency is to swiftly address the critical situation.
Choice B is incorrect as it implies that the timeout is not necessary, which is not accurate.
Choice C is also incorrect as it suggests that the timeout is not required in emergency procedures, disregarding safety protocols.
Choice D is incorrect as it wrongly states that the timeout must be performed in all cases without considering the potential risks associated with delays during emergencies.