13) A nurse is caring for a client who is unconscious and whose partner is their health care surrogate. The partner wishes to discontinue the client’s feeding tube, but another family member tells the nurse that they want the client to continue receiving treatment. Which of the following responses should the nurse make?

“You should contact the provider about your wishes for your family member”

“You should speak with the facility’s ethics committee about your concerns

“We’ll need to have the nursing supervisor review the client’s advance directives”

“As the health care surrogate, the client’s partner can make this decision

Answer and Explanation

The Correct Answer is D

a.   “You should contact the provider about your wishes for your family member”: While involving the provider is essential, it doesn’t directly address the conflicting wishes between the partner and the family member.
b.   “You should speak with the facility’s ethics committee about your concerns”: While acknowledging the need for ethical guidance, this option may not be the most immediate step.
c.   “We’ll need to have the nursing supervisor review the client’s advance directives”: Although reviewing advance directives is crucial, it doesn’t directly address the current disagreement.
d.   “As the health care surrogate, the client’s partner can make this decision”: This response recognizes the legal authority of the health care surrogate (partner) to make decisions on behalf of the unconscious client. It aligns with established principles.

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Correct Answer is B

Explanation

a. This is incorrect because a health care proxy doesn't necessarily have to be a family member. It can be any person chosen by the individual.
b. This is the correct response because it accurately describes the role of a health care proxy, which is to make decisions for the individual when they are unable to do so themselves.
c. This is incorrect because appointing a health care proxy is not contingent upon undergoing an invasive procedure.
d. This is incorrect because the involvement of an attorney is not necessary to appoint a health care proxy.

A. Institute rounds every 2 hr. during the day to offer toileting. B. Keep four side rails up on the beds at night C. Apply vest restraints on the residents who are confused D. Accompany residents older than 85 years of age during ambulation

Correct Answer is A

Explanation

a. Instituting rounds every 2 hours during the day to offer toileting can help prevent falls by addressing residents' toileting needs and reducing the risk of falls associated with attempting to ambulate to the bathroom independently.
b. Keeping four side rails up on the beds at night may increase the risk of entrapment and should be avoided as a fall prevention strategy.
c. Applying restraints, such as vest restraints, is not recommended as a fall prevention measure and may increase agitation and risk of injury.
d. While providing assistance during ambulation is important, it is not necessary to accompany all residents older than 85 years of age. Ambulation assistance should be provided based on individual assessment of mobility and fall risk.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

6) A nurse on a medica-surgical unit is caring for a client who asks about advance directives and states that he wants to appoint a health care proxy. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse at a long-term facility is planning a fall prevention program for the residents. Which of the following interventions should the nurse include?

Correct Answer is A

Explanation

A case manager is preparing a discharge plan for a client following coronary artery bypass grafting surgery. Which of the following client issues should the nurse address first?

A nurse is providing change-of-shift report for an oncoming nurse. Which of the following information should the nurse include in the report?

20) A nurse is developing a discharge plan for a client who is postoperative and will require a wheelchair in the home. The nurse should place a referral to which of the following resources to assist the client with this need?

A nurse is preparing to discharge a client who requires home oxygen. The equipment company has not yet delivered the oxygen tank. Which of the following actions should the nurse take?

A nurse in a clinic is reviewing laboratory reports for a group of clients. Which of the following diseases should the nurse report to the state health department?

A nurse is conducting a disaster preparedness drill with a group of nurses who are orienting to the facility. Which of the following triage tag colors should the nurse instruct the group to apply to a client who has full thickness burns on 72% of his body?

A nurse is caring for four clients. Which of the following clients should the nurse assess first?

A nurse is caring for a client who has a tumor. The provider recommends surgery. The client refuses, but the client's partner wants the surgery performed. Which of the following is the deciding factor in determining if the surgery will be done?