A nurse is teaching a newly licensed nurse about 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 provider can go against the client’s wishes regarding advance directives.

The provider will choose a client’s health care surrogate.

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

Answer and Explanation

The Correct Answer is D

Choice A reason: A health care surrogate does not have to be a family member; clients can designate anyone competent. Assuming family is required shows misunderstanding, risking incorrect surrogate selection, potentially violating client autonomy, critical to avoid in ensuring accurate advance directive implementation in healthcare settings.

Choice B reason: Providers cannot override advance directives unless legally challenged or unclear; they respect client wishes. Assuming providers can go against directives indicates misunderstanding, risking ethical violations, critical to avoid in upholding client autonomy and legal standards in advance directive application during medical decision-making.

Choice C reason: Providers do not choose surrogates; clients designate them in advance directives. Assuming provider choice shows misunderstanding, risking unauthorized decision-making, potentially conflicting with client wishes, critical to prevent in ensuring client-directed care and legal compliance in advance directive processes in healthcare.

Choice D reason: Clients can resume healthcare control after regaining competency, as advance directives apply during incapacity. This understanding ensures respect for autonomy, critical for ethical care, allowing clients to direct decisions once capable, supporting legal and patient-centered implementation of advance directives in temporary incapacity scenarios.

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Correct Answer is A

Explanation

Choice A reason:
A high-pressure alarm indicates increased resistance in the ventilator circuit—most often from secretions, mucus plugs, or patient factors (coughing, biting the tube). Performing endotracheal suctioning removes these obstructions, lowers peak inspiratory pressures, and restores effective ventilation quickly.

Choice B reason:
Requesting a tracheostomy is neither an immediate nor routine response to a high-pressure alarm. Tracheostomy insertion is a planned procedure for long-term airway management, not an acute fix for circuit resistance or secretion buildup.

Choice C reason:
Inspecting the cuff for leaks addresses low-pressure or disconnection alarms, not high-pressure ones. A cuff leak would decrease circuit pressure, triggering a low-pressure alarm, whereas high pressure signals an obstruction or reduced lung compliance.

Choice D reason:
Tightening tubing connections likewise targets leaks or disconnections (low-pressure issues). In a high-pressure situation, the problem lies downstream—increased airway resistance—so securing loose tubing won’t resolve the alarm.

A. Obtain the client's vital signs every other day. B. Allow the client to eat meals in their room. C. Observe the client for 1 hr after meals. D. Weigh the client every 48 hr.

Correct Answer is C

Explanation

Choice A reason: Obtaining vital signs every other day is insufficient for anorexia nervosa, where malnutrition can cause unstable vitals like bradycardia or hypotension. Daily or more frequent monitoring is needed, especially in the first week, making this action inadequate for ensuring patient safety.

Choice B reason: Allowing meals in the room risks unsupervised eating behaviors, such as food hiding or purging, common in anorexia nervosa. Supervised meals in a communal setting ensure intake and prevent compensatory behaviors, making this an inappropriate action for initial care.

Choice C reason: Observing the client for 1 hour after meals prevents purging, a common behavior in anorexia nervosa to avoid weight gain. This supervision ensures nutritional intake is retained, supporting refeeding and monitoring for refeeding syndrome, making it the correct action.

Choice D reason: Weighing every 48 hours is less frequent than needed in early anorexia care, where daily weights monitor refeeding progress and fluid shifts. More frequent weighing ensures timely intervention for complications, making this action less critical than post-meal observation.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While a nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube, the high-pressure alarm on the ventilator sounds. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse in an acute care facility is caring for a client who has anorexia nervosa. During the first week of care, which of the following actions should the nurse take?

Correct Answer is C

Explanation

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