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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale:
a. Administering an enema for a scheduled endoscopy is within the scope of practice for an LPN. It involves a task that is repetitive, stable, and does not require critical thinking.
b. Developing an initial plan of care for a client with sickle cell anemia involves critical thinking and assessment, which are within the scope of practice for an RN.
c. A client transferring from the CCU after a myocardial infarction requires close monitoring and assessment, which are typically within the scope of practice for an RN.
d. Teaching a newly admitted client about self-administration of insulin involves education, assessment, and critical thinking, which are typically within the scope of practice for an RN.

A. “If you have the procedure now, you won’t have to deal with pain and disability later” B. “I understand, and it’s not too late to change your mind” C. “Why didn’t you discuss your concerns with your provider” D. “You’ll be fine. You’ll receive a prescription for pain medication”

Correct Answer is B

Explanation

a. This response may come across as dismissive of the client's concerns and may not address the client's anxiety about pain adequately.
b. This response validates the client's feelings, acknowledges that it's okay to change their mind, and opens the door for further discussion or exploration of alternatives.
c. This response may sound accusatory and may not effectively address the client's immediate concerns.
d. This response does not address the client's worries about pain and may minimize their concerns.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is delegating care for a group of clients. Which of the following clients should the nurse assign to the LPN?

Correct Answer is A

Explanation

A nurse is preparing a client for surgery. The client has signed the consent form but tells the nurse that she has reconsidered because she is worried about the pain. Which of the following responses by the nurse is appropriate?

Correct Answer is B

Explanation

A nurse in a prenatal clinic is caring for a group of clients. Which of the following clients should the nurse recommend for an interdisciplinary care conference?

A nurse enters the hallway and discovers a visitor looking at a client’s medical information on a computer. Which of the following actions should the nurse take first?

14) A nurse is preparing to discharge a client who has end- stage heart failure. the client's partner tells the nurse she can no longer handle caring for the client. which of the following actions should the nurse take?

A nurse is assisting with the orientation of a newly licensed nurse. The newly licensed nurse is having trouble focusing and has difficulty completing care for his assigned clients. Which of the following interventions is appropriate?

A nurse is providing discharge teaching to the parent of a toddler who has a new diagnosis of asthma. The parent states she is unable to afford the nebulizer prescribed for the child. Which of the following referrals should the nurse recommend?

A nurse is caring for a client who has anorexia nervosa. Which of the following interdisciplinary team members should be consulted in regard to this client's care?

A charge nurse notices that two staff nurses are not taking meal breaks during their shifts. Which of the following actions should the nurse take first?

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