Nclex PN Questions and Answers - Nurselytic

Correct Answer: B

Rationale: The correct response is, "For ethical reasons, I am unable to withhold this information from the client."? The ethical principle of veracity requires that the nurse is truthful with the client and does not withhold information even if it is requested by the family.
Choice A is incorrect because seeking a psychiatrist's confirmation is not necessary to uphold the ethical principle of truth-telling.
Choice C is incorrect as implying that signing paperwork overrides the nurse's ethical obligation to be honest with the client is inappropriate.
Choice D is also incorrect as a durable power of attorney is not relevant in this situation where the spouse is asking the nurse to withhold information.

Correct Answer: D

Rationale: The correct answer is the physician. It is the physician's responsibility to ensure that the client provides informed consent by obtaining their signature. While nurses play a crucial role in the healthcare team, their responsibility lies in verifying that the consent process has been completed correctly and advocating for the client. The staff nurse, charge nurse, and LPN do not have the authority to obtain the client's signature on the informed consent form, as this is within the scope of practice of the physician.

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: B

Rationale: Verbal prescriptions should be avoided due to the risk of errors. If a verbal prescription is necessary, it should be promptly written and signed by the healthcare provider, typically within 24 hours. Following agency policies and procedures regarding verbal prescriptions is crucial. In this scenario, the most appropriate nursing action is to request the healthcare provider to document the prescription in the client's record before leaving the unit. Calling the nursing supervisor to accept the verbal prescription without documentation, telling the healthcare provider to delay treatment until documented, and directly changing the IV fluid based on verbal orders all pose risks and do not align with best practices in medication administration.

Correct Answer: C

Rationale: The correct answer is 'a healthcare proxy.' A healthcare proxy involves the client appointing an individual to make medical decisions on their behalf if they become unable to do so. This option allows the client to choose someone they trust to act in their best interests.

Choice A, 'a living will,' is a legal document that outlines a person's wishes regarding medical treatment in case they are unable to communicate their decisions. While it is important, it does not involve appointing someone to make decisions.

Choice B, 'informed consent,' is a process where a healthcare provider explains a treatment or procedure, including its risks and benefits, to a patient who can then decide whether to proceed. This is not about appointing someone to make decisions on the patient's behalf.

Choice D, 'non-informed consent,' is not a valid concept in healthcare. Informed consent is crucial for respecting a patient's autonomy and decision-making capacity.