A nurse is caring for a client who asks for information about advance directives and states, “I want to make sure my wishes are respected.” Which of the following responses should the nurse make?

I cannot be a witness to your advance directives in writing.

Your desire to have advance directives can be included in your medical record.

Your name can be removed from your advance directives at any time.

You must be at least 21 years old to complete advance directives.

Answer and Explanation

The Correct Answer is B

Choice A reason: Nurses can witness advance directives in many settings, depending on state laws, so stating they cannot is inaccurate. This response dismisses the client’s request without providing guidance, making it incorrect and unhelpful for addressing their wishes.
Choice B reason: Including the client’s desire for advance directives in the medical record ensures their wishes are documented and respected. This aligns with the Patient Self-Determination Act, facilitating care planning, making it the correct and supportive response.
Choice C reason: Stating the client’s name can be removed from advance directives is confusing, as directives are personal and revocable, not about name removal. This response is inaccurate and irrelevant to the client’s request, making it incorrect.
Choice D reason: There is no universal age requirement of 21 for advance directives; competent adults (typically 18+) can create them. This statement is incorrect and restrictive, misinforming the client about their rights, making it inappropriate.

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Correct Answer is A

Explanation

Choice A reason: Using a mechanical lift for a 136 kg client unable to assist ensures safety for both client and nurse. Lifts prevent injury by supporting the client’s weight, reducing strain on staff. This adheres to safe patient handling guidelines, minimizing risks of falls or musculoskeletal injuries during transfer.
Choice B reason: Asking another nurse to assist is insufficient for a 136 kg client unable to help, as manual lifting risks injury to staff and client. Mechanical lifts are required for heavy or non-assistive clients to ensure safety, making this option inadequate and unsafe for the transfer scenario described.
Choice C reason: Positioning the client upright before transfer is impractical for a non-assistive client weighing 136 kg, as it requires significant manual effort and risks injury. Mechanical lifts are needed to safely move such clients, ensuring stability and preventing falls, making this action inappropriate for the transfer.
Choice D reason: A sliding board is unsuitable for a 136 kg client unable to assist, as it requires some patient cooperation and strength. It risks injury to staff and client due to the client’s weight and inability to participate. Mechanical lifts are the safer, recommended method for this transfer.

A. Anuria B. Edema C. Hyperkalemia D. Hypocalcemia E. Metabolic acidosis

Correct Answer is ["A","B","C","D","E"]

Explanation

Choice A reason: Anuria, minimal or no urine output, is expected in end-stage kidney disease (ESKD) due to nephron loss, reducing glomerular filtration rate. This causes fluid and toxin buildup, requiring dialysis to manage fluid balance and prevent complications like uremia in ESKD clients.
Choice B reason: Edema results from impaired sodium and water excretion in ESKD, causing fluid overload. Reduced filtration leads to volume retention, manifesting as peripheral or pulmonary edema, increasing cardiovascular strain and necessitating diuretics or dialysis to control fluid status effectively.
Choice C reason: Hyperkalemia occurs in ESKD, as failing kidneys cannot excrete potassium, elevating serum levels. This risks cardiac arrhythmias due to disrupted membrane potentials. Dietary restrictions or dialysis are needed to manage potassium, preventing life-threatening complications in end-stage renal failure.
Choice D reason: Hypocalcemia in ESKD stems from impaired vitamin D activation and phosphate retention, binding calcium. This disrupts bone mineralization and neuromuscular function, causing tetany or fractures. Calcium supplementation and dialysis correct this imbalance, addressing renal failure’s metabolic consequences.
Choice E reason: Metabolic acidosis in ESKD results from impaired hydrogen ion excretion and bicarbonate reabsorption. This lowers blood pH, causing fatigue and bone demineralization. Dialysis or bicarbonate therapy corrects acid-base imbalances, addressing the kidneys’ failure to maintain homeostasis in end-stage disease.

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A nurse is caring for a client who asks for information about advance directives and states, “I want to make sure my wishes are respected.” Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is ["A","B","C","D","E"]

Explanation

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