A nurse is admitting a client who is to undergo a surgical procedure. Under the Patient Self-Determination Act (PSDA), which of the following actions is the nurse's responsibility regarding the client's advance directives?

Assist the client in making decisions about the need for life support.

Notify the provider of the client's durable power of attorney for health care.

Clarify the legal competency of the client.

Ask the client whether they have created advance directives.

Answer and Explanation

The Correct Answer is D

A. Assist the client in making decisions about the need for life support: Nurses can provide education about treatment options, but making decisions about life support is the client’s responsibility, often in consultation with their provider.

B. Notify the provider of the client's durable power of attorney for health care: While important in care planning, notifying the provider is not the nurse’s primary responsibility under the PSDA. The act requires that clients be asked about advance directives and informed of their rights first.

C. Clarify the legal competency of the client: Determining legal competency is a responsibility of the courts, not nurses. Nurses assess decision-making capacity, but under the PSDA, the main role is to ask and provide information about advance directives.

D. Ask the client whether they have created advance directives: The PSDA requires healthcare institutions to inform clients of their right to make decisions regarding their care, including the right to have advance directives. Asking about existing directives fulfills the nurse’s obligation under this law.

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Correct Answer is B

Explanation

A. Insertion of an endotracheal tube: Endotracheal intubation is outside the scope of practice for registered nurses. This procedure is performed by providers such as anesthesiologists, respiratory therapists, or specially trained advanced practice nurses.

B. Monitoring a continuous intra-arterial infusion of a thrombolytic medication: Nurses are responsible for closely monitoring patients receiving high-risk infusions. This includes assessing for complications such as bleeding, changes in vital signs, and effectiveness of therapy, which falls within an RN’s scope of practice.

C. Placement of nylon sutures: Suturing is a procedure performed by providers or advanced practice nurses, not registered nurses. Performing sutures is outside the RN’s scope of practice in most care settings.

D. Administering a bolus dose of medication through an epidural catheter: Epidural bolus administration requires advanced training and is usually limited to anesthesiologists, certified registered nurse anesthetists (CRNAs), or pain specialists.

A. Strong, bounding pulse B. Positive Chvostek's sign C. Hyperactive reflexes D. Decreased bowel sounds

Correct Answer is D

Explanation

A. Strong, bounding pulse: Hypokalemia causes weak, thready, or irregular pulses due to its effects on cardiac muscle excitability. A strong, bounding pulse is more characteristic of hypervolemia or other cardiovascular conditions.

B. Positive Chvostek's sign: A positive Chvostek’s sign is associated with hypocalcemia, not hypokalemia. It indicates neuromuscular excitability due to low calcium levels.

C. Hyperactive reflexes: Hypokalemia generally causes muscle weakness, fatigue, and diminished or hypoactive reflexes rather than hyperactive reflexes.

D. Decreased bowel sounds: Low potassium levels reduce smooth muscle excitability in the gastrointestinal tract, leading to decreased peristalsis and hypoactive bowel sounds, which is a common finding in hypokalemia.

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Body System	Findings
Gastrointestinal	Client reports abdominal pain as a 9 on a pain scale of 0 to 10. Abdomen is distended and firm. Bowels sounds are distant and hypoactive.
Integumentary	Skin is warm and dry. Perianal skin is excoriated, and small ulceration is noted.
Fluid balance	Tenting of skin for 4 seconds is noted. Capillary refill is 2 seconds. Temperature 38.7° C (101.7° F) Mucous membranes are dry. Respiratory rate 20/min

A nurse is admitting a client who is to undergo a surgical procedure. Under the Patient Self-Determination Act (PSDA), which of the following actions is the nurse's responsibility regarding the client's advance directives?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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