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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Change the client's position every 2 hr: Repositioning helps prevent skin breakdown and promotes circulation, which is important for stroke clients. However, it does not address the most immediate risk associated with right-sided weakness and facial drooping.
B. Place the client's right hand in a supination position: Proper positioning of the affected extremities prevents contractures and maintains joint alignment. While necessary for long-term care, it is not the highest priority in the immediate post-stroke period.
C. Maintain NPO status for the client: Right-sided weakness and facial drooping indicate potential dysphagia, placing the client at high risk for aspiration. Maintaining NPO status until a swallowing assessment is completed is the priority to prevent aspiration pneumonia, which is a life-threatening complication.
D. Perform range-of-motion exercises to the client's extremities: Range-of-motion exercises prevent contractures and maintain mobility. While important, this intervention is secondary to ensuring the client’s airway safety and preventing aspiration.
Correct Answer is A
Explanation
A. Extension cords placed under area rugs: Placing extension cords under rugs creates a fire hazard and increases the risk of electrical shock. It can also cause trips and falls if the cords shift or become damaged, making it an unsafe environmental practice.
B. Refrigerator temperature is 3.3° C (38° F): This temperature is within the recommended safe range for storing perishable food, helping prevent bacterial growth. It does not pose a safety hazard.
C. Covers placed on unused electrical outlets: Outlet covers prevent children from inserting objects into outlets, reducing the risk of electrical shock. This is considered a positive safety measure, not a hazard.
D. A lamp plugged directly into a wall outlet: Plugging a lamp directly into a wall outlet is standard and safe when the outlet is not overloaded. It does not present a hazard under normal use.
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