A nurse is evaluating a newly licensed nurse's understanding of advance directives. The newly licensed nurse should identify that which of the following individuals is responsible for deciding whether a client is capable of making their own decisions regarding medical treatment?

Primary provider

Charge nurse

Health care surrogate

Social worker

Answer and Explanation

The Correct Answer is A

A. Primary provider: The primary provider is responsible for assessing a client’s capacity to make their own medical decisions. They determine whether the client is able to understand the nature of their condition and the treatment options available.

B. Charge nurse: While the charge nurse plays an important role in overseeing nursing care and ensuring proper communication, the decision about whether a client is capable of making their own medical decisions falls to the primary provider, not the charge nurse.

C. Health care surrogate: A health care surrogate is an individual designated to make medical decisions for a client when they are unable to do so themselves. However, the primary provider is responsible for determining if the client has the capacity to make decisions before a surrogate is involved.

D. Social worker: Social workers provide support and assistance with advance directives and decision-making, but the responsibility for evaluating whether the client can make medical decisions lies with the primary provider, not the social worker.

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Correct Answer is B

Explanation

A. "You should follow a low cholesterol diet.": While managing cholesterol is important in diabetes care, the primary focus for type 2 diabetes management is controlling blood sugar levels through a balanced diet. Cholesterol management is secondary.

B. "You should follow a balanced intake of carbohydrates, fats, and proteins.": A balanced intake of carbohydrates, fats, and proteins helps regulate blood glucose levels. Carbohydrate counting and distribution are key in diabetes management, and balancing all macronutrients supports optimal blood sugar control and overall health.

C. "You should follow a diet high in vegetables, fiber, and uncooked fruit.": While high fiber intake is beneficial in diabetes management, focusing on vegetables, fiber, and uncooked fruit may limit the client's nutrient intake. A well-rounded, balanced diet is essential.

D. "You should follow a low sodium diet.": Reducing sodium intake is beneficial for heart health, especially in diabetic clients with hypertension. However, controlling blood glucose through a balanced diet should take precedence as the primary focus in managing type 2 DM.

A. "Empty the ostomy pouch when it becomes one-third full of contents." B. "Expect the stoma to turn a purple-blue color as it heals." C. "Cut the opening of the pouch of an inch larger than the stoma” D. "Place a piece of gauze over the stoma while changing the pouch.” E. "Use povidone-iodine to clean around the stoma”

Correct Answer is ["A","C","D"]

Explanation

A. "Empty the ostomy pouch when it becomes one-third full of contents.": It is important to empty the ostomy pouch when it is about one-third full to prevent leakage and pressure on the stoma. This helps avoid skin irritation and maintain comfort.

B. "Expect the stoma to turn a purple-blue color as it heals.": A stoma should be a reddish-pink color. A purple or blue color indicates poor circulation and may signal complications such as ischemia, which requires immediate attention.

C. "Cut the opening of the pouch an inch larger than the stoma.": The opening of the ostomy pouch should be cut about one-quarter to one-half inch larger than the stoma to prevent irritation or pressure on the stoma. This ensures a good fit and reduces risk of skin damage.

D. "Place a piece of gauze over the stoma while changing the pouch.": Placing gauze over the stoma during pouch changes protects the skin around the stoma fromcontact with stooland absorbs any drainage.

E. "Use povidone-iodine to clean around the stoma.": Povidone-iodine is too harsh for cleaning the stoma area and may cause skin irritation. The recommended cleaning solution is warm water and mild soap, followed by proper drying, to avoid skin damage and infection.

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A nurse is evaluating a newly licensed nurse's understanding of advance directives. The newly licensed nurse should identify that which of the following individuals is responsible for deciding whether a client is capable of making their own decisions regarding medical treatment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching for a client who has a recent diagnosis of type 2 diabetes mellitus. Which of the following information should the nurse prioritize in the teaching for a diabetic diet?

Correct Answer is B

Explanation

A nurse is completing discharge teaching about ostomy care with a client who has a new stoma. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

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