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A client who is at risk for pressure ulcers and has an albumin level of 4.2 g/dL

A client who has Type 1 diabetes and uses an insulin pump

A client who is receiving heparin and has an aPTT of 34 seconds

A client who has orthostatic hypotension and is receiving IV fluids

Answer and Explanation

The Correct Answer is A

Choice A Reason:
A client who is at risk for pressure ulcers and has an albumin level of 4.2 g/dL is correct. This client has multiple risk factors for developing pressure ulcers, including a low albumin level. An interdisciplinary conference would be beneficial to involve various healthcare professionals, such as wound care specialists, dietitians, and physical therapists, to develop a comprehensive plan of care to prevent and manage pressure ulcers.
Choice B Reason:
A client who has Type 1 diabetes and uses an insulin pump is incorrect. While managing Type 1 diabetes requires coordination among healthcare providers, the use of an insulin pump alone may not necessitate an interdisciplinary conference unless there are specific concerns or issues that require input from multiple disciplines.
Choice C Reason:
A client who is receiving heparin and has an aPTT of 34 seconds is incorrect. Monitoring heparin therapy and adjusting doses based on laboratory values such as activated partial thromboplastin time (aPTT) is typically within the purview of the nursing and medical team. An interdisciplinary conference may not be necessary unless there are complications or concerns that require input from other healthcare professionals.
Choice D Reason:
A client who has orthostatic hypotension and is receiving IV fluids is incorrect. Orthostatic hypotension and IV fluid management are often managed primarily by the nursing and medical team. While input from other disciplines may be valuable in certain cases, it may not warrant scheduling an interdisciplinary conference unless there are specific complexities or challenges that require input from multiple disciplines.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A Reason:
Raising all four side rails on the bed of a confused client can be considered a form of restraint, which should be avoided unless necessary for the safety of the patient. It may infringe on the client's autonomy and dignity.
Choice B Reason:
Electing not to care for a client who had an abortion is discriminatory and violates the principle of nonmaleficence (doing no harm). Nurses have a professional obligation to provide care to all patients regardless of their personal beliefs or circumstances.
Choice C Reason:
Withholding nutrition from a client with a do-not-resuscitate (DNR) order without clear medical indications goes against the principle of beneficence and could be considered unethical. Nutritional support is a basic aspect of care that should not be withheld unless it is medically indicated or aligns with the patient's wishes.
Choice D Reason:
A nurse administers prescribed opioids to a client who has a terminal illness and respiratory rate of 8/min represents ethical practice because administering prescribed opioids to a client with a terminal illness and a respiratory rate of 8/min is appropriate and aligns with the principle of beneficence. The nurse's action aims to alleviate the client's pain and suffering, which is essential in end-of-life care.

A. Withdraws the medication from the ampule using a subcutaneous needle B. Breaks the top of the ampule using an antiseptic wipe C. Disposes of the ampule by placing it in a sharp’s container D. Performs 3 checks of the medication before administration

Correct Answer is A

Explanation

Choice A Reason:
Withdraws the medication from the ampule using a subcutaneous needle is the correct answer. Medication from an ampule should be withdrawn using a filter needle or a needle specifically designed for ampule use, not a subcutaneous needle. Using the wrong type of needle can lead to contamination or injury to the nurse or the client.
Choice B Reason:
Breaks the top of the ampule using an antiseptic wipe is incorrect answer. Breaking the top of the ampule using an antiseptic wipe helps maintain sterility during the process. It is a standard practice to wipe the neck of the ampule with an antiseptic wipe before breaking it open to reduce the risk of contamination.
Choice C Reason:
Disposes of the ampule by placing it in a sharp’s container is incorrect answer. Disposing of the used ampule in a sharp’s container is the appropriate method for safe disposal of sharps to prevent needlestick injuries.
Choice D Reason:
Performs 3 checks of the medication before administration is incorrect answer. Performing three checks of the medication before administration is a standard safety practice to ensure accuracy and prevent medication errors. This includes checking the medication label against the medication administration record (MAR) or prescription, checking the medication against the MAR or prescription while preparing it, and checking the medication again before administering it to the client.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse provides an annual in-service for the nursing staff regarding ethical practice. Which of the following actions should the nurse include as an example of ethical practice?

Correct Answer is D

Explanation

A nurse is observing a newly licensed nurse prepare a medication from an ampule for a client's injection. For which of the following actions by the newly licensed nurse should the nurse intervene?

Correct Answer is A

Explanation

A client who is unconscious and has extensive internal injuries arrives via ambulance to the emergency department. The staff cannot reach the client's family. Which of the following permits the staff to proceed with emergency surgery?

A nurse manager is reviewing isolation guidelines with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding of isolation guidelines?

A charge nurse is evaluating a newly licensed nurse and presents a performance improvement plan to the nurse for remediation. Which of the following outcomes should indicate to the charge nurse that the plan has been effective?

A nurse in the emergency department is preparing to care for a client who arrived via ambulance. The client is disoriented and has a cardiac arrhythmia. Which of the following actions should the nurse take?

A nurse manager observes an assistive personnel (AP) incorrectly transferring a client to the bedside commode. Which of the following actions should the nurse take first?

A nurse is evaluating the time management skills of a newly licensed nurse. Which of the following actions by the newly licensed nurse should the nurse identify as an indication of effective time management?

A charge nurse witnesses an assistive personnel (AP) failing to follow facility protocol when discarding contaminated linens. Which of the following actions should the nurse take first?

A nurse is preparing to fax information to a rehabilitative facility prior to transferring a client. Which of the following actions should the nurse plan to take?