A nurse is caring for a client who is unresponsive and has advance directives stating they do not want treatment to extend their life. The client's partner is their health care surrogate and requests the nurse begin tube feedings. Which of the following responses should the nurse make?

"The ethics committee will need to make that decision."

"The client's wishes are to not be given life-saving treatment."

"Your partner will feel better with tube feeding."

"We should discuss this with the rest of your partner's family."

Answer and Explanation

The Correct Answer is B

A. Involving the ethics committee may be unnecessary if the client's advance directives are clear.

B. This response directly addresses the client's wishes as stated in their advance directives, reinforcing the importance of honoring their preferences regarding life-sustaining treatment.

C. Suggesting that tube feeding will make the client feel better contradicts the advance directives and does not respect the client's wishes.

D. Discussing the matter with the rest of the family may not be appropriate if the partner is the designated surrogate and the client's wishes are clearly outlined in the advance directives.

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Correct Answer is B

Explanation

A. Changing total parenteral nutrition (TPN) tubing every 48 hours is incorrect. According to most guidelines, TPN tubing should be changed every 24 hours to reduce the risk of infection.

B. Changing peripheral IV primary tubing every 96 hours is a recommended practice in many healthcare settings. It balances infection prevention with cost-effectiveness and is widely accepted for maintaining IV line sterility.

C. Replacing peripheral IV solution bags every 96 hours would not be appropriate, as IV fluid bags should typically be replaced every 24 hours to prevent bacterial contamination.

D. Replacing TPN solution bags every 48 hours is not advisable, as TPN solutions should be replaced every 24 hours to minimize infection risks associated with high-sugar content solutions.

A. Make arrangements to take over the client's care. B. Recommend that both nurses be terminated. C. Contact the house supervisor to mediate the conflict. D. Escort the nurses to the nurses' lounge to continue the discussion.

Correct Answer is D

Explanation

A. Taking over the client's care may temporarily solve the problem but does not address the conflict or facilitate a resolution between the two nurses.

B. Termination is an extreme action and is not warranted in this situation. Conflict resolution should be attempted before considering disciplinary actions.

C. While mediation may be helpful, it is not the most immediate solution in this situation. The charge nurse can initially intervene directly to de-escalate the situation.

D. Escorting the nurses to the lounge allows them to continue the conversation in a more private setting, away from patients and other staff, reducing disruption to the work environment. It also gives the charge nurse a chance to mediate and calm the situation.

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A nurse is caring for a client who is unresponsive and has advance directives stating they do not want treatment to extend their life. The client's partner is their health care surrogate and requests the nurse begin tube feedings. Which of the following responses should the nurse make?

Nursing Test Bank

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