6) A nurse on a medica-surgical unit is caring for a client who asks about advance directives and states that he wants to appoint a health care proxy. Which of the following responses should the nurse make?

“You must choose a member of your family to serve as your health care proxy”

“A health care proxy can make decisions for you when you are unable to do so”

“You should appoint a health care proxy before undergoing an invasive procedure”

“It is necessary for an attorney to approve your health care proxy”

Answer and Explanation

The Correct Answer is B

a.   This is incorrect because a health care proxy doesn't necessarily have to be a family member. It can be any person chosen by the individual.
b.   This is the correct response because it accurately describes the role of a health care proxy, which is to make decisions for the individual when they are unable to do so themselves.
c.   This is incorrect because appointing a health care proxy is not contingent upon undergoing an invasive procedure.
d.   This is incorrect because the involvement of an attorney is not necessary to appoint a health care proxy.

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Correct Answer is D

Explanation

a. While a client with type 1 diabetes using an insulin pump may require interdisciplinary collaboration for optimal management, this scenario does not suggest an immediate need for an interdisciplinary conference.
b. A client receiving heparin with an aPTT of 34 seconds may require adjustment of the heparin dosage, but this situation does not necessitate an interdisciplinary conference.
c. A client with orthostatic hypotension receiving IV fluids may require close monitoring and collaboration among healthcare providers, but this situation does not suggest an immediate need for an interdisciplinary conference.
d. A client at risk for pressure ulcers with an albumin level of 4.2 g/dl may require an interdisciplinary conference to address nutrition, wound care, and preventive measures to reduce the risk of pressure ulcer development.

A. Review the chart for nonrestraint alternatives for agitation B. Inform the unit manager C. Speak with the AP about the incident D. Remove the restraints from the client’s wrist

Correct Answer is D

Explanation

a. Review the chart for nonrestraint alternatives for agitation: While reviewing alternatives is important, the immediate concern is ensuring the safety and well-being of the client by removing the restraints.
b. Inform the unit manager: While it's important to inform the unit manager, the first action should be to address the immediate safety issue by removing the restraints.
c. Speak with the AP about the incident: While it's important to discuss the incident with the assistive personnel, the first priority is to remove the restraints to prevent harm to the client.
d. Remove the restraints from the client’s wrist: This is the correct action to take first to ensure the client's safety and prevent further harm. Afterward, the nurse can address the situation with the assistive personnel and review alternatives for managing the client's agitation.

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6) A nurse on a medica-surgical unit is caring for a client who asks about advance directives and states that he wants to appoint a health care proxy. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is working on a medical-surgical unit and is managing the care of four clients. The nurse should schedule an interdisciplinary conference for which of the following clients?

Correct Answer is D

Explanation

A charge nurse making rounds observes that assistive personnel has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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