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 B
Explanation
- A. Incorrect. The nurse should check the functioning of oxygen equipment daily, not weekly, to ensure safety and proper delivery of oxygen.
- B. Correct. The nurse should instruct the client to wear clothing made with cotton fabrics while oxygen is in use, as synthetic fabrics can generate static electricity and cause sparks that could ignite the oxygen.
- C. Incorrect. The nurse should instruct the client to avoid petroleum-based lubricants, such as Vaseline, as they are flammable and could cause burns if exposed to oxygen. The nurse should recommend water-soluble lubricants, such as K-Y jelly, instead.
- D. Incorrect. The nurse should instruct the client to store full oxygen tanks upright, not on their side, to prevent them from rolling and damaging the valve or regulator.
Correct Answer is ["B","C","E","F"]
Explanation
The four findings that require follow-up are B, C, E, and F.
Rationale:
- Blood pressure: A normal blood pressure for an adolescent is 110/70 mm Hg. The question does not provide the adolescent's blood pressure, so it cannot be determined if it requires followup or not.
- Capillary refill: A normal capillary refill time is less than 2 seconds. A prolonged capillary refill time indicates impaired blood flow to the extremity, which could be due to vascular injury, compartment syndrome, or shock.
- Pedal pulse: A normal pedal pulse is +2 or +3. A weak pedal pulse (+1) indicates reduced blood flow to the extremity, which could be due to vascular injury, compartment syndrome, or shock.
- Heart rate: A normal heart rate for an adolescent is 60 to 100 beats per minute. The question does not provide the adolescent's heart rate, so it cannot be determined if it requires follow-up or not.
- Skin temperature: A normal skin temperature is warm and dry. A cool skin temperature indicates reduced blood flow to the extremity, which could be due to vascular injury, compartment syndrome, or shock.
- Pain: A pain level of 10 on a scale of 0 to 10 indicates severe pain that needs to be managed with appropriate analgesics and nonpharmacological interventions.
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