A nurse is caring a client who is unconscious and whose partner is their health care surrogate. The partner wishes to discontinue the client’s feeding tube, but another family member tells the nurse that they want the client to continue receiving treatment. Which of the following responses should the nurse make?

“You should contact the provider about your wishes to your family member.”

“You should speak with the facility’s ethics committee about your concerns.”

“We’ll need to have the nursing supervisor review the client’s advance directives.”

“As the health care surrogate, the client’s partner can make this decision.”

Answer and Explanation

The Correct Answer is D

a. "You should contact the provider about your wishes for your family member."

While the provider may ultimately be involved in decision-making, it's important for the nurse to address the conflicting wishes and provide guidance on the appropriate steps to take in such situations.

b. "You should speak with the facility’s ethics committee about your concerns."

In cases of conflicting wishes or ethical dilemmas, involving the ethics committee can be beneficial. However, this response might not address the immediate need for clarification and guidance.

c. "We’ll need to have the nursing supervisor review the client’s advance directives."

Reviewing advance directives with the nursing supervisor is a reasonable step to ensure that the client's wishes are documented and followed. However, it might not directly address the conflicting wishes or provide immediate resolution.

d. "As the health care surrogate, the client’s partner can make this decision."

This is the correct response. The health care surrogate, appointed by the client or legally recognized as such, has the authority to make medical decisions on behalf of the unconscious client. It's important to follow the client's advance directives and legal designations regarding

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Correct Answer is A

Explanation

a. A client with Alzheimer's disease and bacterial pneumonia with newly onset restlessness may be experiencing delirium, which could indicate a worsening of their pneumonia or another underlying issue. Delirium can be a sign of a serious medical condition and requires immediate assessment to determine the cause and provide appropriate intervention.

b. While a fasting blood glucose level of 200mg/dL in a newly admitted client with diabetes mellitus is high and requires attention, it is not as urgent as assessing a client with newly onset restlessness, as described in option a.

c. A client who is 24 hours postoperative following surgical reduction of a hip fracture and reports a pain level of 7 on a scale from 0-10 requires assessment and pain management, but it is not as urgent as assessing the client with newly onset restlessness.

d. A client who is 3 days postoperative following abdominal surgery and is ready for discharge may require routine assessment and preparation for discharge, but it is not as urgent as assessing the client with newly onset restlessness.

A. “You can ask an AP to teach a simple task to a client.” B. “You should assign tasks you are unfamiliar with to an experienced AP.” C. “If you are unsure about an AP’s ability, observe them performing the task.” D. “The person who delegates a task is not held accountable for the outcome.”

Correct Answer is C

Explanation

a. "You can ask an AP to teach a simple task to a client."

While assistive personnel may assist with client education under the supervision of a licensed nurse, the primary responsibility for teaching tasks to clients usually rests with licensed healthcare providers.

b. "You should assign tasks you are unfamiliar with to an experienced AP."

Delegating tasks to assistive personnel should be based on their competency and the complexity of the task, not necessarily on the nurse's familiarity with it. It is essential to delegate tasks that the AP is trained and competent to perform.

c. "If you are unsure about an AP’s ability, observe them performing the task."

This is the correct statement. It emphasizes the importance of assessing an assistive personnel's competence by observing their performance before delegating tasks, especially if there is uncertainty about their abilities.

d. "The person who delegates a task is not held accountable for the outcome."

This statement is incorrect. The person delegating a task is ultimately accountable for ensuring that the task is performed correctly and safely. Delegation does not relieve the delegator of accountability.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for four clients. Which of the following should the nurse assess first?

Correct Answer is A

Explanation

A nurse is teaching a newly licensed nurse about delegating tasks to assistive personnel. Which of the following statements should the nurse make?

Correct Answer is C

Explanation

A nurse enters the hallway and discovers a visitor looking at a client’s medical information on a computer. Which of the following actions should the nurse take first?

A charge nurse witnesses an assistive personnel failing to follow facility protocol when discarding contaminated linens. Which of the following actions should the nurse take first?

A nurse overhears two assistive personnel discussing a client’s care in the cafeteria. Which of the following actions should the nurse take?

A nurse is caring for a client who has cancer the client’s adult child asks the nurse for information about the client’s treatment plan. Which of the following responses should the nurse make?

A charge nurse is observing a licensed practical nurse assist a client who has dysphagia while eating. Which of the following actions by the LPN should the charge nurse identify as providing safe care?

A nurse is caring for a client who has a new diagnosis of chlamydia. Which of the following actions should the nurse take?

A nurse in a long-term care facility is caring for a client who reports the assistive personnel repositioned him in bed using excessive force. Which of the following actions should the nurse take?

Nurses on an inpatient care unit are working to help reduce unit costs. Which of the following actions is appropriate to include in the cost-containment plan?