A charge nurse is teaching a newly licensed nurse about clients designating a health care proxy in situations that require a durable power of attorney for health care (DPAHC). Which of the following information should the charge nurse include?

"The proxy should manage legal issues for the client."

"The proxy can make treatment decisions if the client is under anesthesia."

The proxy can make financial decisions if the need arises."

The proxy should make health care decisions for the client regardless of the client's ability to do so "

Answer and Explanation

The Correct Answer is B

A. "The proxy should manage legal issues for the client." Legal matters are outside the scope of a health care proxy’s role. The proxy is authorized only to make medical decisions and does not handle legal or court-related concerns on behalf of the client.
B. "The proxy can make treatment decisions if the client is under anesthesia." The health care proxy is activated when the client is temporarily or permanently incapacitated, such as during surgery under anesthesia. At that point, the proxy can make treatment decisions aligned with the client’s values and previously expressed wishes.
C. "The proxy can make financial decisions if the need arises." Financial decisions are the responsibility of a financial power of attorney, not a health care proxy. A DPAHC limits the proxy’s authority strictly to medical and treatment-related decisions.
D. "The proxy should make health care decisions for the client regardless of the client's ability to do so." The health care proxy is not active while the client is competent and able to make decisions. The proxy only assumes responsibility when the client lacks decision-making capacity due to illness, unconsciousness, or cognitive impairment.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Determine if the stockings are binding. It is important to assess that antiembolic stockings are not too tight, especially around the top, as this can impair circulation. Proper fit ensures they function effectively to promote venous return and prevent deep vein thrombosis.
B. Fold the top of the stocking over neatly. Folding or rolling the tops can cause constriction and act like a tourniquet, reducing circulation and increasing the risk of complications such as venous stasis or skin breakdown.
C. Apply the stockings after the client is in a chair. Antiembolic stockings should be applied while the client is lying down, before getting up, to prevent blood pooling in the legs. Applying them after the client is upright may reduce their effectiveness.
D. Massage the client's legs once every 8 hr while the stockings are in place. Massaging the legs, especially in clients at risk for thrombosis, is not recommended as it could dislodge a clot and lead to embolism. Passive or active leg movement is safer and more effective.

A. The stoma appears dark purple in color. B. The colostomy has had no output. C. The client refuses to look at the colostomy. D. The client reports a pain level of 6 on a scale from 0 to 10

Correct Answer is A

Explanation

A. The stoma appears dark purple in color. This is a priority finding, as it may indicate impaired circulation or necrosis of the stoma tissue. A healthy stoma should appear pink or red and moist. A dark purple or black color requires immediate evaluation.
B. The colostomy has had no output. While it is important to monitor output, it is not unusual for a new colostomy to have minimal or no output in the first 24–48 hours post-op as bowel function returns.
C. The client refuses to look at the colostomy. This is a psychosocial concern and may indicate body image issues or denial, but it is not the most urgent issue in the immediate postoperative period.
D. The client reports a pain level of 6 on a scale from 0 to 10. Pain management is important, but a pain level of 6, while needing intervention, does not take priority over a potential vascular compromise of the stoma.

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A charge nurse is teaching a newly licensed nurse about clients designating a health care proxy in situations that require a durable power of attorney for health care (DPAHC). Which of the following information should the charge nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is wearing antiembolic stockings. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is A

Explanation

A nurse is assessing a client who had a colostomy 24 hrs ago. Which of the following findings is the nurse's priority?

Correct Answer is A

Explanation

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