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 C
Explanation
A. The infant is swaddled but there is a blanket and a stuffed toy in the crib. Loose items increase the risk of suffocation and SUID, so this does not demonstrate safe sleep practices.
B. The infant is placed on their back, but there is a blanket and a stuffed toy in the crib. These items pose a suffocation risk and do not follow safe sleep guidelines.
C. The infant is placed on their back in a swaddle with no loose blankets or toys in the crib. This position aligns with American Academy of Pediatrics (AAP) recommendations for safe sleep to reduce the risk of SUID, demonstrating proper understanding of safe sleep practices.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
Rationale for correct choices
• Pulmonary embolism: The client exhibits sudden onset of dyspnea, chest discomfort, tachypnea, hypoxemia (oxygen saturation 92% on 2 L O₂), and appears in respiratory distress, all of which are classic signs of a pulmonary embolism. Postoperative orthopedic patients, especially after hip arthroplasty, are at high risk due to immobility, venous stasis, and hypercoagulability.
• Recent surgery: The client’s recent total hip arthroplasty increases the risk of thromboembolic events. Surgical procedures, particularly major orthopedic surgeries, create a hypercoagulable state and contribute to venous stasis, which can precipitate a pulmonary embolism.
Rationale for incorrect choices
• Pneumothorax: Pneumothorax typically presents with unilateral chest pain, sudden shortness of breath, and decreased or absent breath sounds on one side. The client’s crackles are bilateral and S3/S4 heart sounds are present, which are not consistent with pneumothorax.
• Pneumonia: Although the client has fever and crackles, the sudden onset of symptoms and acute respiratory distress are more consistent with pulmonary embolism rather than pneumonia, which usually develops gradually. Additionally, the timing shortly after surgery favors a thromboembolic event over an infectious process.
• Tobacco use: The client reports no history of tobacco use, making this an irrelevant risk factor for the current acute episode.
• Activity level: While immobility can contribute to thrombus formation, the client ambulated with assistance earlier, and the more significant risk factor remains recent surgery, which directly predisposes to pulmonary embolism.
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