A nurse is teaching participants at a community center about advance directives. Which of the following information should the nurse include in the teaching?
A client must create a do-not-resuscitate order when completing advance directives.
Advance directives cannot be changed once implemented.
Assigning a health care surrogate requires legal consultation.
A health care surrogate makes health care decisions when the client is no longer able.
The Correct Answer is D
Rationale:
A. A client must create a do-not-resuscitate order when completing advance directives: A DNR is a separate medical order and is not required when completing advance directives. Clients may choose to include resuscitation preferences in their directive but are not obligated to.
B. Advance directives cannot be changed once implemented: Advance directives are flexible documents that can be revised or revoked by the client at any time, as long as the client is mentally competent. This allows clients to adjust their wishes as circumstances or preferences change.
C. Assigning a health care surrogate requires legal consultation: While laws vary by state, in most cases, a legal consultation is not required. Clients can designate a surrogate by completing a form that is often available at healthcare facilities or through state-provided templates.
D. A health care surrogate makes health care decisions when the client is no longer able: A surrogate, also known as a durable power of attorney for health care, steps in only when the client loses decision-making capacity. This ensures that the client’s preferences are respected when they cannot communicate them.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. "You can lift objects that weigh 15 pounds.": Clients recovering from retinal detachment repair should avoid lifting heavy objects, even as light as 15 pounds. Increased intraocular pressure from straining can compromise the surgical repair.
B. "Pick up items by bending at the waist.": Bending at the waist increases intraocular pressure and should be avoided postoperatively. Clients are advised to bend at the knees and keep their head upright to reduce pressure on the eye.
C. "Avoid reading for 3 days following surgery.": Reading is usually restricted only if it causes eye strain or requires eye movement that could interfere with healing. It is not routinely restricted for a set number of days unless otherwise specified by the surgeon.
D. "Take a stool softener daily.": Straining during bowel movements increases intra-abdominal and intraocular pressure. Stool softeners help prevent straining, making them a useful part of postoperative care after eye surgery to protect the surgical site.
Correct Answer is B
Explanation
Rationale:
A. Insert the catheter into the foot: While the scalp and foot veins may be used in infants, foot veins are less preferred in mobile infants due to the risk of dislodgement. Site selection should prioritize accessible and secure veins, often in the hand or scalp.
B. Obtain a 24-gauge catheter: A 24-gauge catheter is the appropriate size for infants due to their small and delicate veins. It minimizes trauma during insertion and allows for adequate flow while reducing the risk of vein damage.
C. Use gauze to cover the IV insertion site: Transparent dressings, not gauze, are preferred for covering IV sites in infants. They allow for continuous visualization of the site to detect signs of infiltration or infection promptly.
D. Monitor the IV site every 8 hours: IV sites in infants should be monitored much more frequently due to their higher risk of infiltration, dislodgement, or phlebitis. Hourly monitoring is standard practice, especially in high-acuity or pediatric settings.
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