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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Correct Answer is C

Explanation

A. Widening pulse pressure. This is typically associated with conditions like increased intracranial pressure or severe aortic regurgitation, not cardiac tamponade. Tamponade usually results in narrowed pulse pressure.
B. Coarse lung sounds. These may indicate fluid overload or pulmonary congestion, but they are not specific to cardiac tamponade and occur later or in different conditions.
C. Muffled heart sounds. This is a classic early sign of cardiac tamponade, caused by fluid accumulation in the pericardial sac, which dampens heart sounds on auscultation. It is part of Beck’s triad (muffled heart sounds, hypotension, and jugular vein distention).
D. Decreased jugular vein distention. In cardiac tamponade, jugular vein distention increases due to impaired venous return to the heart. Decreased JVD would be an unexpected finding in this condition.

A. Activate the facility's fire alarm system. B. Close all nearby windows and doors. C. Use the unit's fire extinguisher to attempt to put out the fire. D. Transport the client to another area of the nursing unit.

Correct Answer is D,A,B,C

Explanation

D. Transport the client to another area of the nursing unit. The first priority is rescue ensuring the client’s safety by removing them from the immediate area of danger, which is consistent with the "RACE" fire safety protocol (Rescue, Alarm, Contain, Extinguish).

A. Activate the facility's fire alarm system. Once the client is safe, the next step is to activate the fire alarm to notify other staff and initiate emergency protocols throughout the facility.

B. Close all nearby windows and doors. Containing the fire by closing doors and windows limits the spread of smoke and flames, buying time for response teams to arrive and control the situation.

C. Use the unit's fire extinguisher to attempt to put out the fire. If it is safe and the fire is small and manageable, the final step is to extinguish the fire using a fire extinguisher, following appropriate safety procedures.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is postoperative following a coronary artery bypass graft surgery. The nurse should identify that which of the following findings is an early indication of cardiac tamponade?

Correct Answer is C

Explanation

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Correct Answer is D,A,B,C

Explanation

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