NCLEX - LEGAL ETHICAL Day1 (Part 1)

The nurse in the emergency department is caring for a client who is unconscious and requires an emergency craniotomy. The client has no identification. The nurse should recognize that it would be a priority to

• document medical necessity of the surgical procedure in the client's medical record
• transport the client to the operating room under the premise of implied consent
• contact the local police to help identify the client and locate family members
• obtain court permission for the client's surgical procedure

Answer explanation

Option 1: document medical necessity of the surgical procedure in the client's medical record

Option 2: transport the client to the operating room under the premise of implied consent

Option 3: contact the local police to help identify the client and locate family members

Option 4: obtain court permission for the client's surgical procedure

Correct Answer: Option 2

Explanation:

Informed consent is required for many procedures (eg, nonemergency surgery). For clients who cannot provide consent due to unconsciousness in a medical emergency, consent is considered implied and life-saving treatment should be provided without delay.

A housekeeping employee tells the staff nurse of having a headache and asks for acetaminophen. How should the nurse respond?

• Ask about liver disease and give acetaminophen from the nurse's personal supply
• Assess the employee's blood pressure
• Check for allergies to drugs before giving acetaminophen from hospital stock
• Refer employee to the employee health provider

Answer explanation

Option 1: Ask about liver disease and give acetaminophen from the nurse's personal supply

Option 2: Assess the employee's blood pressure

Option 3: Check for allergies to drugs before giving acetaminophen from hospital stock

Option 4: Refer employee to the employee health provider

Correct Answer: Option 4

Explanation:

Although acetaminophen is over-the-counter, nurses should not administer it without a prescription or formal assessment. Refer to employee health for evaluation.

The nurse finds a client on the floor in the client's room. Based on the documentation shown in the exhibit, the nurse made an incorrect entry in the client's medical record at what time?

• 1700
• 1710
• 1740
• 1810

Answer explanation

Option 1: 1700

Option 2: 1710

Option 3: 1740

Option 4: 1810

Correct Answer: Option 3

Explanation:

Incident reports must not be referenced in the client’s medical record. Objective documentation should be recorded without mention of report filing.

The nurse in the outpatient care facility is caring for a client with metastatic lung cancer who received chemotherapy 3 days ago. The client states, "I have decided that I do not want to continue treatment." Which of the following responses would be appropriate for the nurse to make?

• That is not an easy choice to make. I will notify your health care provider of your decision.
• Have you considered how this decision might affect your spouse and children?
• I do not think it is wise to stop chemotherapy. You will become too sick to enjoy your life.
• Have you discussed this decision with someone else that you trust?

Answer explanation

Option 1: That is not an easy choice to make. I will notify your health care provider of your decision.

Option 2: Have you considered how this decision might affect your spouse and children?

Option 3: I do not think it is wise to stop chemotherapy. You will become too sick to enjoy your life.

Option 4: Have you discussed this decision with someone else that you trust?

Correct Answer: Option 1

Explanation:

Autonomy allows clients to make their own health care decisions. The nurse should notify the HCP and support the client’s informed decision.

A newly reassigned nurse enters a hospital room at the beginning of the shift and finds the client unconscious and unresponsive. Resuscitation is initiated and then continued by the rapid response team. The nurse realizes that there is a do not resuscitate (DNR) prescription posted in the client's chart. Which action is correct?

• Stop all resuscitation activity immediately
• Continue resuscitation until DNR status is verified with health care provider
• If client shows any signs of life, follow advanced cardiovascular support protocol until stable
• Once resuscitation has begun, complete it regardless of client code status

Answer explanation

Option 1: Stop all resuscitation activity immediately

Option 2: Continue resuscitation until DNR status is verified with health care provider

Option 3: If client shows any signs of life, follow advanced cardiovascular support protocol until stable

Option 4: Once resuscitation has begun, complete it regardless of client code status

Correct Answer: Option 1

Explanation:

Resuscitation must end immediately after discovery of a valid DNR directive, even if started in error.

The nurse is caring for a client who has no pulse and is experiencing the cardiac rhythm in the ECG strip shown below. The client has a do not attempt resuscitation directive. The health care provider orders initiation of resuscitative measures. Which of the following actions should the nurse take?

• Initiate chest compressions.
• Clarify the order with the HCP.
• Prepare the client for defibrillation.
• Verify the client's wishes with the family.

Answer explanation

Option 1: Initiate chest compressions.

Option 2: Clarify the order with the HCP.

Option 3: Prepare the client for defibrillation.

Option 4: Verify the client's wishes with the family.

Correct Answer: Option 2

Explanation:

A DNAR is legally binding and the nurse must advocate for the client's wishes by clarifying any contradictory orders with the HCP.

The nurse is providing end-of-life care to a client who has a do not attempt resuscitation directive. The client's respirations are 6/min. Which of the following actions should the nurse take?

• Administer oxygen at 2 L/min via nasal cannula.
• Obtain the spouse's consent for endotracheal intubation.
• Determine if the client has a power of attorney for health care.
• Ask the client if any changes have been made to the DNAR directive.

Answer explanation

Option 1: Administer oxygen at 2 L/min via nasal cannula.

Option 2: Obtain the spouse's consent for endotracheal intubation.

Option 3: Determine if the client has a power of attorney for health care.

Option 4: Ask the client if any changes have been made to the DNAR directive.

Correct Answer: Option 1

Explanation:

Oxygen for comfort is permissible and not considered resuscitation; focus on comfort care in DNAR situations.

Which client in the emergency department would be allowed to leave against medical advice after the risks are discussed with the primary health care provider?

• 5-year-old client with meningitis whose parent refuses antibiotics
• Client who attempted suicide by taking a handful of acetaminophen an hour ago
• Client with a urinary tract infection who is disoriented to time and place
• Client with coffee-ground emesis from chronic use of high-dose aspirin

Answer explanation

Option 1: 5-year-old client with meningitis whose parent refuses antibiotics

Option 2: Client who attempted suicide by taking a handful of acetaminophen an hour ago

Option 3: Client with a urinary tract infection who is disoriented to time and place

Option 4: Client with coffee-ground emesis from chronic use of high-dose aspirin

Correct Answer: Option 4

Explanation:

Competent clients have the right to leave AMA even if it’s not medically advised; the bleeding client is competent.

The acute care clinic nurse administers a prescribed narcotic for a client with renal colic and then discharges the client without ensuring that the client has a designated driver. The client is subsequently involved in a motor vehicle accident causing injury to self and others. Which ethical principle did the nurse violate?

• Autonomy
• Nonmaleficence
• Paternalism
• Veracity

Answer explanation

Option 1: Autonomy

Option 2: Nonmaleficence

Option 3: Paternalism

Option 4: Veracity

Correct Answer: Option 2

Explanation:

Nonmaleficence means “do no harm”; the nurse acted without ensuring safety after narcotic administration.

A client receiving end-of-life care is no longer able to make decisions. The client's appointed medical power of attorney is considering placement of a feeding tube. The MPOA asks the nurse, "What would you do if this was your family member?" How should the nurse respond?

• I'm not sure what I would do, but I feel confident that you will make the right decision.
• I will call the chaplain to help you sort through the options and discuss the issue.
• What do you think are the advantages and disadvantages of a feeding tube?
• You should meet with the family to discuss what the patient would have wanted.

Answer explanation

Option 1: I'm not sure what I would do, but I feel confident that you will make the right decision.

Option 2: I will call the chaplain to help you sort through the options and discuss the issue.

Option 3: What do you think are the advantages and disadvantages of a feeding tube?

Option 4: You should meet with the family to discuss what the patient would have wanted.

Correct Answer: Option 3

Explanation:

Therapeutic response involves helping the decision-maker think through pros and cons without giving personal opinion.