the advanced directive in a clients chart is dated august 12 1998the clients daughter produces a power of attorney for health care dated 2003 which co

NCLEX-PN

Nclex Questions Management of Care

1. The advanced directive in a client's chart is dated August 12, 1998. The client's daughter produces a Power of Attorney for Health Care, dated 2003, which contains different care directions. What should the nurse do?

A. Follow the 1998 version because it's part of the legal chart.
B. Follow the 1998 version because the physician's code order is based on it.
C. Follow the 2003 version, place it in the chart, and communicate the update appropriately.
D. Follow neither until clarified by the unit manager.

Correct answer: C

Rationale: The document dated 2003 supersedes the previous version and should be used as a basis for care directions. The nurse should follow the 2003 version, place it in the chart, and communicate the update appropriately to ensure that the most current care directions are followed. Choices A and B are incorrect because the 1998 version is now outdated, and the nurse should not rely on it for care decisions. Choice D is incorrect because the nurse should not delay following the updated document, and seeking clarification from the unit manager can lead to avoidable delays in care.

2. What are the hazards of improper splinting?

A. Aggravation of a bone or joint injury
B. Reduced distal circulation
C. Delay in transporting a client with a life-threatening injury
D. All of the above

Correct answer: D

Rationale: Hazards of improper splinting can lead to the aggravation of a bone or joint injury, reduced distal circulation, and delay in transporting a client with a life-threatening injury. Choosing 'All of the above' (Option D) is the correct answer as it encompasses all the hazards mentioned. Option A is incorrect because it only addresses one aspect of the hazards. Option B is incorrect as it does not cover all the hazards associated with improper splinting. Option C is incorrect as it focuses on only one hazard and does not account for the others.

3. A nurse is planning task assignments for the day. Which assignment is the least appropriate for the nursing assistant?

A. Assisting a client with dysphagia in eating
B. Ambulating a client with Parkinson's disease
C. Providing hygiene to a client with dementia
D. Assisting a client with an above-the-knee amputation in showering

Correct answer: A

Rationale: The least appropriate assignment for a nursing assistant would be assisting a client with dysphagia in eating. This task requires specialized skills and knowledge to prevent complications such as choking and aspiration. Ambulating a client with Parkinson's disease, providing hygiene to a client with dementia, and assisting a client with an above-the-knee amputation in showering are tasks that a nursing assistant can safely perform without significant risk of complications. Assisting a client with dysphagia in eating involves higher risks and requires specific training, making it the least appropriate choice for a nursing assistant.

4. A nursing instructor asks a nursing student to describe accountability. Which statement(s) by the student indicate(s) an accurate description of accountability?

A. Check the unit policy for the protocol for the care of clients who have been sexually assaulted.
B. Ask a medical assistant.
C. Call the nurse in charge of the day shift.
D. Ask the police officers who brought the client to the center.

Correct answer: A

Rationale: Accountability in nursing involves taking responsibility for one's actions and decisions. In this scenario, checking the unit policy for the protocol related to the care of sexually assaulted clients demonstrates accountability. Policies and protocols provide guidance on appropriate actions and responsibilities in specific situations. Asking a medical assistant, calling the day shift nurse in charge, or consulting police officers are not appropriate actions to demonstrate accountability in this context. Seeking further clarification from the agency nursing supervisor on the night shift after reviewing the policy or protocol would be a more suitable course of action.

5. Which is the proper hand position for performing chest percussion?

A. Use the side of the hands
B. Flatten the hands
C. Spread the fingers of both hands
D. Cup the hands

Correct answer: D

Rationale: The proper hand position for performing chest percussion is to cup the hands. Cupping the hands helps produce a vibration that aids in loosening respiratory secretions effectively. This technique is essential for therapeutic chest physiotherapy. Using the side of the hands, flattening the hands, or spreading the fingers of both hands do not generate the necessary vibration required for chest percussion. These hand positions are not considered proper techniques in this context and may not provide the desired therapeutic effect.