A nurse is caring for an older adult client who reports difficulty making health-related decisions. The client asks if it is possible to have a trusted friend make these decisions. Which of the following actions should the nurse take first?
Call the provider to discuss the client's preference with them and their family.
Explain to the client the process of designating another individual to make decisions for them.
Ask the client to discuss these preferences with their family first.
Ask the client if they would like their wishes documented in their health care records.
The Correct Answer is B
A. Call the provider to discuss the client's preference with them and their family: While involving the provider and family is important, the first step should be to educate the client about their options for designating a decision-maker.
B. Explain to the client the process of designating another individual to make decisions for them: The nurse should first provide information about how the client can designate a trusted individual to make decisions for them, such as through a durable power of attorney for healthcare. This allows the client to make an informed decision.
C. Ask the client to discuss these preferences with their family first: The nurse should first empower the client by explaining the process of designating a decision-maker. It is crucial to respect the client’s autonomy in making this decision before involving family.
D. Ask the client if they would like their wishes documented in their health care records: Before documenting, the nurse should ensure the client understands the process of assigning a decision-maker. Documentation is important, but the client needs to understand their options first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Assess the client every hr for circulation, possible injury, and readiness for discontinuation: While regular assessment is necessary, it should be done more frequently than every hour. A check every 15-30 minutes is recommended for safety.
B. Check the client's peripheral pulses and skin integrity every 15 min: Frequent assessments of circulation, skin integrity, and injury help prevent complications like tissue damage or nerve impairment.
C. Assist the client with passive range of motion exercises every 3 hr: Passive range of motion exercises should be done more frequently than every 3 hours to prevent stiffness and joint contractures.
D. Attach the extremity restraint straps to the bed rails using a quick-release buckle: Restraints should never be attached to bed rails, as this increases injury risk. Straps should be secured to a stationary part of the bed frame.
Correct Answer is A
Explanation
A. Set the suction device to 120 mm Hg: For nasopharyngeal suctioning in adults, the suction pressure should typically be set between 100 and 120 mm Hg to prevent injury to the mucous membranes while effectively clearing secretions.
B. Apply suction to the catheter during insertion: Suction should not be applied during insertion of the catheter, as this can cause trauma to the mucous membranes. Suctioning should only occur when the catheter is in the appropriate position and being withdrawn.
C. Have the client tuck his chin to his chest during suctioning: The client should not tuck the chin to the chest during suctioning. Instead, the client should be asked to either cough or breathe normally. Tucking the chin may obstruct the airway and make suctioning difficult.
D. Apply a petroleum-based lubricant to the catheter: Petroleum-based lubricants should not be used as they can cause a fire hazard when oxygen is present. Instead, a water-soluble lubricant should be applied to the catheter if needed.
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