a client is refusing to stay in the hospital because he does not agree with his healthcare treatment plan the nurse stops the client from leaving due
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Nursing Elites

NCLEX-PN

Nclex PN Questions and Answers

1. A client is refusing to stay in the hospital because he does not agree with his healthcare treatment plan. The nurse stops the client from leaving due to concern for his health. Which of these legal charges could the nurse face?

Correct answer: A

Rationale: Refusing to let a client leave against medical advice (AMA) is a form of false imprisonment. In this scenario, the nurse is restricting the client's freedom of movement by preventing him from leaving the hospital, even though he has expressed his wish to leave. False imprisonment is a legal charge the nurse could face in this situation. The other options are incorrect: - Malpractice refers to professional negligence or failure to provide adequate care, not allowing a patient to make their own decisions. - Invasion of privacy involves disclosing confidential information without consent, not preventing a patient from leaving. - Negligence is the failure to take reasonable care, but it does not specifically address the act of restricting a patient from leaving against their wishes.

2. The LPN notices a client with poor gait and balance. She is currently being treated for hypertension, but the nurse is concerned. What should the nurse do?

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.

3. When removing a client's gown with an intravenous line, what should the nurse do?

Correct answer: C

Rationale: The correct action when removing a client's gown with an intravenous line is to thread the bag and tubing through the gown sleeve while keeping the line intact. This method ensures that the system remains sterile and reduces the risk of infection. Temporarily disconnecting the tubing at a point close to the client or from the container introduces the potential for contamination. Cutting the gown with scissors should only be done in emergencies as it is not a standard practice and can compromise the integrity of the intravenous line. Therefore, the most appropriate and safe method is to thread the bag and tubing through the gown sleeve.

4. The LPN needs to delegate a task to the nurse aide who is new to the unit. Which of these is the best option for the nurse to choose in proceeding?

Correct answer: B

Rationale: Delegation is transferring responsibility for a task but sharing its accountability. It is the delegator's responsibility to ensure that the delegatee understands the task before it is performed and to follow up afterward to ensure it was completed correctly and safely. Option B is the best choice because it allows the nurse to observe the nurse aide performing the task without pressure, which can provide insights into the aide's abilities and understanding. This method also allows for immediate feedback and correction if needed. Choice A is incorrect because confirming understanding alone may not provide a complete picture of the aide's competence in performing the task. Choice C is incorrect as it suggests supervising only if needed, which may not provide adequate oversight for a new nurse aide. Choice D is incorrect because supervising the task being performed does not allow for an objective assessment of the aide's abilities and understanding.

5. Which of the following statements indicates adequate dietary understanding in a client with constipation?

Correct answer: C

Rationale: The correct answer is, "I should increase my intake of apples."? This statement indicates adequate dietary understanding in a client with constipation because apples are a good source of fiber, which helps alleviate constipation. Adequate fiber intake is essential for promoting bowel regularity. Choices A and B are incorrect as decreasing fluids and activity level can worsen constipation. Insufficient fluid intake can lead to hard stools, exacerbating constipation. Decreasing activity can also slow down bowel movements. Choice D is incorrect because milk is not a high-fiber food and may not effectively address constipation. While milk can have a mild laxative effect on some individuals, it is not a primary solution for constipation, especially when compared to high-fiber foods like apples.

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