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

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

a. Document an objective description of the situation:

It is important to start by documenting the observed behavior objectively. This documentation can serve as a factual record of the incident.

b. Schedule a formal meeting with the LPN within 48 hours:

While addressing the issue promptly is important, scheduling a formal meeting should come after documenting the situation. The initial step is to gather information and document observations.

c. Interview clients about the nurse’s actions:

Interviewing clients may be necessary later in the investigation process, but the immediate action should be to document the observed behavior and then proceed with a more formal investigation if needed.

d. Check the unit narcotic records for discrepancies:

The issue at hand appears to be related to alcohol use rather than narcotics. While discrepancies in narcotic records might be a concern, it may not be the most relevant action based on the situation described.

A. Institute rounds every 2 hr during the day to offer toileting B. Apply vest restraints on residents who are confused C. Accompany residents older than 85 years of age during ambulation D. Keep the four side rails up on beds at night

Correct Answer is A

Explanation

a. Institute rounds every 2 hr. during the day to offer toileting:

This intervention is appropriate as it helps address the need for toileting assistance, which can reduce the risk of falls associated with residents attempting to ambulate to the bathroom independently. Regular toileting rounds can help prevent falls related to toileting urgency or difficulty.

b. Keep four side rails up on the beds at night:

Keeping all four side rails up on the beds can increase the risk of entrapment and may not be necessary for all residents. Using bed rails should be individualized based on each resident's risk assessment and should follow facility policies and guidelines to prevent entrapment and ensure resident safety.

c. Apply vest restraints on the residents who are confused:

Using restraints, such as vest restraints, should be avoided whenever possible due to the increased risk of physical and psychological harm to residents. Restraints do not address the underlying causes of falls and can contribute to agitation, loss of mobility, and pressure injuries.

d. Accompany residents older than 85 years of age during ambulation:

This intervention is appropriate, especially for residents who are at increased risk of falls, such as those over 85 years of age. Accompanying residents during ambulation allows for assistance and support, reduces the risk of falls, and provides an opportunity for early intervention if balance or mobility issues arise.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse manager observes a licensed practical nurse who has a strong odor of alcohol on their breath. Which of the following actions should the nurse manager take?

Correct Answer is A

Explanation

A nurse at a long-term care facility is planning a fall prevention program for the residents. Which of the following interventions should the nurse include?

Correct Answer is A

Explanation

A nurse on a medical-surgical unit is evaluating an assistive personnel’s use of infection control precautions. Which of the following actions by the AP indicates correct use of the precautions?

A nurse in a prenatal clinic is caring for a group of clients. Which of the following clients should the nurse recommend for an interdisciplinary care conference?

A home health nurse is assessing an older adult client’s home after providing teaching about home safety. Which of the following actions by the client indicates an understanding of the teaching?

A nurse is comparing the rate of medication errors on the medical unit to the rate from a medical unit in a magnet hospital. Which of the following quality improvement methods is the nurse using?

A hospice nurse is caring for a client who has a terminal illness and reports severe pain. After the nurse administers the prescribed opioid and benzodiazepine, the client becomes somnolent and difficult to arouse. Which of the following actions should the nurse take?

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 conducting a disaster preparedness drill with a group of nurses who are orienting to the facility. Which of the following triage tag colors should the nurse instruct the group to apply to a client who has full thickness burns on 72% of his body?

A nurse is assessing a client who has meningitis. Which of the following findings should the nurse report to the provider immediately?