A nurse is caring for a client who is comatose. The client has a living will that declines the use of artificial enteral nutrition as a life-sustaining measure, but the client's family has requested that the staff begin tube feedings. Which of the following actions should the nurse take?
Insert the tube and begin feedings per the family's request.
Ask the provider to discuss the issue with the family.
Report the dilemma to the facility's dietitian.
Review the client's request with the family.
The Correct Answer is D
The correct answer is Choice D: Review the client's request with the family.
Choice D rationale: Reviewing the client's request with the family respects the client's autonomy and the directives stated in their living will. It allows the nurse to communicate and clarify the client's wishes with the family, helping them understand the decisions made by the client when they were competent. This action promotes open communication and may facilitate resolution of the conflict.
Choice A rationale: Inserting the tube and beginning feedings per the family's request disregards the client's living will, which explicitly declines the use of artificial enteral nutrition as a life-sustaining measure. This action goes against the ethical principle of autonomy and could have legal implications.
Choice B rationale: While asking the provider to discuss the issue with the family could be a subsequent step, it is not the primary action to take in this situation. The nurse should first review the client's request with the family to emphasize the importance of the living will and facilitate understanding between the parties involved.
Choice C rationale: Reporting the dilemma to the facility's dietitian does not address the ethical and legal concerns at hand. The dietitian's role is to manage nutritional needs, not to resolve ethical dilemmas or interpret legal documents such as living wills. Involving the dietitian may not be helpful in addressing the conflict between the client's wishes and the family's request.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Digoxin is a medication used to treat heart conditions like heart failure and atrial fibrillation. A digoxin level of 1.0 ng/mL is within the therapeutic range (usually 0.5-2.0 ng/mL), indicating that the client's digoxin dosage is appropriate. However, this value doesn't indicate an urgent need for a home visit.
Choice B rationale:
A white blood cell count (WBC) of 6,000/mm³ falls within the normal range (typically 4,500-11,000/mm³). While this value could suggest a stable immune system, it doesn't provide information requiring immediate attention or a home visit.
Choice C rationale:
Platelets are essential for blood clotting. A platelet count of 100,000/mm³ is significantly below the normal range (usually 150,000-450,000/mm³), indicating a risk of bleeding and potentially a serious medical condition. This client is at risk for spontaneous bleeding and requires prompt assessment and intervention, making this choice the correct answer.
Choice D rationale:
A serum potassium level of 4.0 mEq/L falls within the normal range (typically 3.5-5.0 mEq/L). While maintaining electrolyte balance is important, this potassium level doesn't indicate an immediate need for a home visit.
Correct Answer is D
Explanation
Answer is: d. "Clients are the experts on their own pain."
Explanation: The charge nurse's response acknowledges the client's self-report of pain, which is considered the most reliable indicator of pain presence and intensity. This approach emphasizes the importance of individualized pain management and respects the client's autonomy.
Statement a. is wrong because the nurse is suggesting an intervention without assessing the client's pain or consulting the healthcare provider. Although nonpharmacological interventions may be appropriate, they should be discussed with the client and provider before making decisions.
Statement b. is wrong because withholding prescribed medication without a valid reason or consultation with the healthcare provider is inappropriate and could result in inadequate pain management.
Statement c. is wrong because contacting mental health services for a consultation based on the assumption that the client is seeking drugs may be premature and overlook the client's reported pain. A thorough assessment and discussion with the healthcare provider should precede any consultation.
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