A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make?

They allow the court to overrule an adult client’s refusal of medical treatment.

They indicate the form of treatment a client is willing to accept in the event of a serious illness.

They permit a client to withhold medical information from health care personnel.

They allow health care personnel in the emergency department to stabilize a client’s condition.

Answer and Explanation

The Correct Answer is B

Choice A rationale

This statement is incorrect. Advance directives do not allow the court to overrule an adult client’s refusal of medical treatment. They are legal documents that provide instructions for medical care and only go into effect if the individual cannot communicate their own wishes.

Choice B rationale

This statement is correct. Advance directives indicate the form of treatment a client is willing to accept in the event of a serious illness. They allow individuals to express their preferences about medical treatment at some point in the future, should they become unable to communicate their wishes.

Choice C rationale

This statement is incorrect. Advance directives do not permit a client to withhold medical information from health care personnel. They are used to communicate the individual’s wishes about medical treatment to their healthcare providers and family.

Choice D rationale

This statement is incorrect. Advance directives do not specifically allow health care personnel in the emergency department to stabilize a client’s condition. They are used to guide choices for doctors and caregivers if the individual is terminally ill, seriously injured, in a coma, in the late stages of dementia or near the end of life.

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Correct Answer is C

Explanation

Choice A rationale

Assisting the client to a left side-lying position with the right knee flexed is a common position for administering an enema. However, this action alone would not address the client’s immediate need for relief from constipation.

Choice B rationale

Preparing the client for a chest x-ray would not be the most appropriate action based on the client’s symptoms. The client is experiencing abdominal pain and constipation, which are not typically associated with conditions that would require a chest x-ray.

Choice C rationale

Administering a cleansing enema is the correct action. The client has not had a bowel movement for the past 7 days and reports abdominal pain. These symptoms, along with the findings from the abdominal x-ray, suggest that the client is experiencing constipation. A

cleansing enema can help to relieve constipation by stimulating bowel movements and removing impacted fecal matter.

Choice D rationale

Auscultating the client’s bowel sounds is an important part of assessing the client’s gastrointestinal status. However, given the client’s symptoms and the results of the abdominal x-ray, administering a cleansing enema would be the most appropriate action.

A. Assist the patient into a prone position. B. Place a sleeve over the top of each leg with the opening facing up. C. Make sure two fingers can fit under the sleeves. D. Set the ankle pressure at 65 mm Hg. .

Correct Answer is C

Explanation

Choice A rationale

Assisting the patient into a prone position is not necessary for the use of thigh-length sequential compression sleeves. These devices are typically used while the patient is in bed or sitting in a chair.

Choice B rationale

Placing a sleeve over the top of each leg with the opening facing up is not the correct method for applying sequential compression sleeves. The sleeves should be applied so that they fit snugly and comfortably around the patient’s legs.

Choice C rationale

The nurse should ensure that two fingers can fit under the sleeves. This is to ensure that the sleeves are not too tight, which could impede blood flow and cause discomfort or injury to the patient.

Choice D rationale

Setting the ankle pressure at 65 mm Hg is not related to the use of sequential compression sleeves. The pressure settings for these devices are typically determined by the healthcare provider based on the patient’s specific needs.

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A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client in the emergency department reports abdominal pain and has not had a bowel movement for the past 7 days. Based on the client’s clinical findings, which action should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a patient who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves.Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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