A nurse is admitting a client who is to undergo a surgical procedure. Under the Patient Self-Determination Act (PSDA), which of the following actions is the nurse's responsibility regarding the client's advance directives?

Assist the client in making decisions about the need for life support.

Notify the provider of the client's durable power of attorney for health care.

Clarify the legal competency of the client.

Ask the client whether they have created advance directives.

Answer and Explanation

The Correct Answer is D

A. Assist the client in making decisions about the need for life support: Nurses can provide education about treatment options, but making decisions about life support is the client’s responsibility, often in consultation with their provider.

B. Notify the provider of the client's durable power of attorney for health care: While important in care planning, notifying the provider is not the nurse’s primary responsibility under the PSDA. The act requires that clients be asked about advance directives and informed of their rights first.

C. Clarify the legal competency of the client: Determining legal competency is a responsibility of the courts, not nurses. Nurses assess decision-making capacity, but under the PSDA, the main role is to ask and provide information about advance directives.

D. Ask the client whether they have created advance directives: The PSDA requires healthcare institutions to inform clients of their right to make decisions regarding their care, including the right to have advance directives. Asking about existing directives fulfills the nurse’s obligation under this law.

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Correct Answer is B

Explanation

A. Palpate each of the four quadrants of the abdomen to a depth of 4 cm (1.5 in): Palpation assesses tenderness, masses, or organ enlargement but does not evaluate peristalsis. Palpating too soon postoperatively can also cause discomfort or disrupt healing.

B. Auscultate each of the four quadrants for 5 min before determining sounds are absent: Bowel sounds indicate peristalsis, and a full 5 minutes of auscultation is required before concluding they are absent, especially after abdominal surgery where bowel activity may be reduced.

C. Percuss each of the four quadrants of the abdomen: Percussion evaluates the presence of fluid, gas, or organ borders but does not provide information about bowel motility. It is useful for assessing distention but not peristalsis.

D. Inspect each of the four quadrants for abdominal distention: Inspection identifies visible abnormalities such as distention, scars, or pulsations. While distention may suggest reduced peristalsis, visual inspection alone does not confirm bowel activity.

A. Place a vibrating tuning fork on the top of the client's head. B. Move a vibrating tuning fork's prongs in front of the client's left or right ear canal. C. Activate a tuning fork and place the prongs on the client's occipital area. D. Instruct the client to occlude one ear and repeat a softly spoken phrase by the nurse.

Correct Answer is B

Explanation

A. Place a vibrating tuning fork on the top of the client's head: This describes the Weber test, which assesses lateralization of sound to determine conductive versus sensorineural hearing loss.

B. Move a vibrating tuning fork's prongs in front of the client's left or right ear canal: In the Rinne test, the nurse compares bone conduction and air conduction. After placing the fork on the mastoid bone, it is moved in front of the ear canal to test air conduction, which should normally be longer than bone conduction.

C. Activate a tuning fork and place the prongs on the client's occipital area: Placing the tuning fork on the occipital bone is not part of any standard hearing assessment test. It would not yield useful information about bone or air conduction.

D. Instruct the client to occlude one ear and repeat a softly spoken phrase by the nurse: This describes the whisper test, a screening tool for gross hearing acuity. It is not related to the Rinne test procedure.

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A nurse is admitting a client who is to undergo a surgical procedure. Under the Patient Self-Determination Act (PSDA), which of the following actions is the nurse's responsibility regarding the client's advance directives?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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