A nurse is caring for a client who has not completed their advance directives. Which of the following actions should the nurse take?
Advise the family that a spiritual advisor will explain what life-sustaining measures are
Intervene if the client makes a health care decision the nurse does not agree with
Ensure the client has identified a health care surrogate.
Inform the client that once advance directives have been agreed upon, no changes can be implemented.
The Correct Answer is C
A. Advise the family that a spiritual advisor will explain what life-sustaining measures are: While spiritual advisors can provide support, the nurse should focus on ensuring the client understands their rights and options rather than delegating decision-making explanations to family or advisors. The client’s autonomy is the priority.
B. Intervene if the client makes a health care decision the nurse does not agree with: The nurse must respect the client’s autonomy and decisions regarding their care, even if they personally disagree. Intervening based on personal beliefs violates ethical and legal principles of patient rights.
C. Ensure the client has identified a health care surrogate: Helping the client designate a health care surrogate ensures that someone is authorized to make decisions if the client becomes incapacitated. This is a critical step in advance care planning and aligns with legal and ethical standards.
D. Inform the client that once advance directives have been agreed upon, no changes can be implemented: Advance directives can be updated or revoked at any time while the client is competent. Providing inaccurate information could limit the client’s rights and autonomy, so the nurse should clarify that changes are always possible.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Speak to a first-level manager about the social media post: Reporting the social media post to a first-level manager ensures that the situation is handled through proper administrative and professional channels. This protects client confidentiality, aligns with HIPAA regulations, and maintains professional accountability.
B. Gather additional information from other colleagues: Seeking additional information from peers may violate confidentiality and is not an appropriate method for addressing potential breaches of client privacy. The concern should be escalated through formal reporting channels rather than informal investigation.
C. Inform the client about the social media post: Directly informing the client may not be appropriate without guidance from administration or risk management, as it could complicate investigation or legal procedures. The issue should first be reported to management for proper handling.
D. Ask the colleague why the information was posted: Confronting the colleague directly could lead to defensiveness, workplace conflict, or compromised evidence. The appropriate first step is to report the concern to a supervisor rather than attempt immediate resolution with the colleague.
Correct Answer is D
Explanation
A. "Empty the drainage bag every 12 hours.": Urine should be emptied regularly, but not on a fixed 12-hour schedule. The focus is on preventing backflow and maintaining sterility, so the bag should be emptied when it is two-thirds full or as needed, rather than strictly every 12 hours.
B. "Irrigate the indwelling urinary catheter once per shift.": Routine irrigation is not recommended for preventing catheter-associated urinary tract infections (CAUTIs) and can introduce pathogens or cause trauma. Irrigation should only be performed if specifically indicated for obstruction or provider order.
C. "Apply a topical antimicrobial ointment as part of routine catheter care.": Routine application of antimicrobial ointment is not recommended and does not prevent CAUTIs. Proper hygiene and sterile technique are more effective in infection prevention than topical agents.
D. "Keep the drainage bag below the level of the bladder.": Maintaining the drainage bag below the bladder prevents backflow of urine, which is a major risk factor for introducing bacteria into the urinary tract. This simple intervention is a key measure in reducing catheter-associated urinary tract infections.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.