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?
"The provider will choose a client's health care surrogate.”
"A health care surrogate must be a family member.”
"The provider can go against the client's wishes regarding advance directives.”
"The client can resume control of health care after a temporary loss of competency.”
The Correct Answer is D
Choice A rationale:
The provider does not choose a client's healthcare surrogate. Advance directives, including the appointment of a healthcare surrogate, allow individuals to make their own decisions about their medical treatment if they become unable to communicate their wishes. Clients have the right to designate their healthcare surrogate based on their preferences and values. This statement is incorrect as it misrepresents the purpose of advance directives.
Choice B rationale:
A healthcare surrogate does not need to be a family member. The choice of a healthcare surrogate is a personal decision made by the individual. It can be a family member, friend, or any other person whom the individual trusts to make medical decisions on their behalf. There is no requirement that the surrogate must be a family member.
Choice C rationale:
The provider cannot go against the client's wishes regarding advance directives. Advance directives are legally binding documents that outline the individual's preferences for medical treatment, including decisions to withhold or withdraw life-sustaining interventions. Healthcare providers are ethically and legally obligated to respect and follow the directives outlined by the client. Going against the client's wishes would be a violation of their autonomy and legal rights.
Choice D rationale:
The client can resume control of healthcare decisions after a temporary loss of competency if specified in the advance directives. Advance directives often include provisions stating that the individual's decision-making capacity should be
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
- A. Incorrect. Evaluating dietary intake requires nursing judgment and knowledge of nutrition and eating disorders. This task should not be delegated to an AP.
- B. Incorrect. Measuring vital signs of a postoperative client requires nursing assessment and monitoring for complications. This task should not be delegated to an AP.
- C. Correct. Arranging the lunch tray for a client who has a hip fracture is a routine task that does not require nursing skills or judgment. This task can be delegated to an AP.
- D. Incorrect. Assessing I&O for a client who is receiving dialysis requires nursing knowledge of fluid and electrolyte balance and renal function. This task should not be delegated to an AP.
Correct Answer is ["B","C","E","F"]
Explanation
- A. Bowel sounds are hypoactive in all four quadrants, which is expected after an appendectomy due to anesthesia and decreased peristalsis. This is not a finding that needs to be reported to the provider.
- B. Oxygen saturation is 93% on room air, which is below the normal range of 95% to 100%. This could indicate impaired gas exchange, respiratory depression, or infection. This is a finding that needs to be reported to the provider.
- C. Nausea is a common feature of appendicitis and should go away with appendectomy. This finding should, therefore, be reported to the healthcare provider.
- D. Vomiting is also a common side effect of morphine and anesthesia, and can be managed with antiemetics and fluids. This is not a finding that needs to be reported to the provider unless it persists or interferes with oral intake.
- E. Pain level is 6 on a scale of 0 to 10.The client received morphine as prescribed at 1815, and the pain level is still significant. This isa finding that needs to be reported to the provider
- F. Heart rate is 110/min, which is above the normal range of 60 to 100/min. This could indicate pain, anxiety, dehydration, infection, or bleeding. This is a finding that needs to be reported to the provider.
- G. Incision characteristics are clean and dry, which is expected after an appendectomy. However, the nurse should monitor for signs of infection such as redness, swelling, warmth, drainage, or odor. This is a finding that needs to be reported to the provider if any signs of infection are present.
- H. Lungs sounds are clear on auscultation, which is expected after an appendectomy. However, the nurse should encourage deep breathing and coughing exercises to prevent atelectasis and pneumonia. This is a finding that needs to be reported to the provider if any abnormal lung sounds are heard such as crackles, wheezes, or diminished breath sounds.
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