A nurse is teaching a newly licensed nurse about advance directives. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"A health care surrogate must be a family member."

"The client can resume control of health care after a temporary loss of competency."

"The provider will choose a client's health care surrogate."

"The provider can go against the client's wishes regarding advance directives."

Answer and Explanation

The Correct Answer is B

A. "A health care surrogate must be a family member.": This statement is incorrect. A health care surrogate, also known as a health care proxy or agent, does not necessarily have to be a family member. It can be any individual chosen by the client to make health care decisions on their behalf if they become unable to do so.
B. "The client can resume control of health care after a temporary loss of competency.": This statement demonstrates an understanding of advance directives. Advance directives allow individuals to maintain control over their health care decisions by specifying their preferences for treatment or appointing a surrogate decision-maker. If a client experiences a temporary loss of competency, they can regain control of their health care decisions once competency is restored.
C. "The provider will choose a client's health care surrogate.": This statement is incorrect. It is the responsibility of the client to choose their health care surrogate. While healthcare providers may provide guidance and information about advance directives, they do not choose the surrogate for the client.
D. "The provider can go against the client's wishes regarding advance directives.": This statement is incorrect. Advance directives are legally binding documents that express a client's wishes regarding medical treatment. Healthcare providers are generally obligated to follow the directives outlined in these documents, and they cannot go against the client's wishes unless certain legal exceptions apply, such as emergency situations where immediate action is required to preserve life.

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Correct Answer is A

Explanation

Answer: A

Rationale:

A. Frequent swallowing: Frequent swallowing in a postoperative tonsillectomy patient can be a sign of bleeding or a hemorrhage. This is a priority finding because it may indicate that the child is swallowing blood, which requires immediate intervention to prevent significant blood loss and complications.

B. Dark brown emesis: Dark brown emesis can be a normal finding post-tonsillectomy, as it may indicate the presence of old blood or clotted blood. While it should be monitored, it is not as urgent as frequent swallowing, which may signify active bleeding.

C. Sore throat: A sore throat is a common postoperative symptom following a tonsillectomy and is generally expected. It is important to manage pain and discomfort, but it is not as urgent as signs of potential bleeding.

D. Blood-tinged mucus: Blood-tinged mucus can occur after a tonsillectomy due to irritation or minor bleeding. While it should be observed, it is less critical compared to frequent swallowing, which may indicate more significant bleeding.

A. Obtain urinary samples by disconnecting the tubing connections. B. Secure the catheter to the client's thigh. - C. Keep the urinary bag at bladder level when ambulating. D. Loop the tubing so that it is lower than the collection bag.

Correct Answer is B

Explanation

A. Obtain urinary samples by disconnecting the tubing connections:
This action increases the risk of contamination and introduces bacteria into the urinary system, potentially leading to UTIs. Urine samples should be obtained using a sterile technique to minimize the risk of infection.

B. Secure the catheter to the client's thigh:
Securing the catheter to the client's thigh can cause tension and traction on the catheter, increasing the risk of urethral trauma and introducing bacteria into the urinary tract. Catheters should be secured without tension to prevent damage to the urethra and reduce the risk of UTIs.

C. Keep the urinary bag at bladder level when ambulating:
Keeping the urinary bag at bladder level when ambulating prevents urine from flowing back into the bladder, reducing the risk of UTIs. Gravity drainage helps maintain the flow of urine and prevents stasis, which can contribute to bacterial growth and UTIs.

D. Loop the tubing so that it is lower than the collection bag:
Looping the tubing so that it is lower than the collection bag creates a dependent loop where urine can accumulate, increasing the risk of bacterial colonization and UTIs. The tubing should be kept straight and free of kinks to ensure continuous drainage and prevent urine from pooling in the tubing.

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A nurse is teaching a newly licensed nurse about advance directives. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings should the nurse identify as the priority?

Correct Answer is A

Explanation

A nurse is planning care for a client who has a history of urinary tract infections (UTIs) and requires placement of an indwelling urinary catheter. Which of the following actions should the nurse take to help minimize the client's risk for acquiring a UTI?

Correct Answer is B

Explanation

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