A nurse is caring for a client who asks for information about advance directives and states, “I want to make sure my wishes are respected.” Which of the following responses should the nurse make?

I cannot be a witness to your advance directives in writing.

Your desire to have advance directives can be included in your medical record.

Your name can be removed from your advance directives at any time.

You must be at least 21 years old to complete advance directives.

Answer and Explanation

The Correct Answer is B

Choice A reason: Nurses can witness advance directives in many settings, depending on state laws, so stating they cannot is inaccurate. This response dismisses the client’s request without providing guidance, making it incorrect and unhelpful for addressing their wishes.
Choice B reason: Including the client’s desire for advance directives in the medical record ensures their wishes are documented and respected. This aligns with the Patient Self-Determination Act, facilitating care planning, making it the correct and supportive response.
Choice C reason: Stating the client’s name can be removed from advance directives is confusing, as directives are personal and revocable, not about name removal. This response is inaccurate and irrelevant to the client’s request, making it incorrect.
Choice D reason: There is no universal age requirement of 21 for advance directives; competent adults (typically 18+) can create them. This statement is incorrect and restrictive, misinforming the client about their rights, making it inappropriate.

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Correct Answer is C

Explanation

Choice A reason: Dehydration is not directly associated with gastroesophageal reflux, which involves gastric acid backflow. Dehydration affects fluid balance, not reflux mechanisms, so this statement is inaccurate and irrelevant to preterm contractions, making it incorrect.
Choice B reason: Dehydration is not caused by decreased hemoglobin and hematocrit; rather, it may elevate these due to hemoconcentration. This statement reverses the relationship, making it factually incorrect and unrelated to preterm labor risks.
Choice C reason: Dehydration can increase preterm labor risk by reducing uterine blood flow and triggering contractions via oxytocin release. This evidence-based link supports hydration as a preventive measure, making it the correct statement for teaching in this scenario.
Choice D reason: Dehydration is treated with fluid replacement, not calcium supplements, which address bone health or specific deficiencies. This treatment is irrelevant to dehydration or preterm labor, making it an incorrect and inappropriate recommendation.

A. The client advances the walker and takes a step towards it. B. The client takes multiple steps while holding the walker. C. The client grasps the walker by the hand grips on the upper bars. D. The client lifts the walker as it is moved forward.

Correct Answer is B

Explanation

Choice A reason: Advancing the walker and taking a step towards it is the correct technique, ensuring stability by moving the walker first, then stepping. This maintains balance and prevents falls, aligning with safe walker use protocols, so no intervention is needed for this action.
Choice B reason: Taking multiple steps while holding the walker compromises stability, as the walker must be repositioned after each step to ensure support. This increases fall risk, requiring the charge nurse to intervene to correct the technique and ensure the client’s safety during ambulation.
Choice C reason: Grasping the walker by the hand grips on the upper bars is correct, as it provides optimal control and balance. This standard technique supports safe mobility, and no intervention is required, as it adheres to proper walker use guidelines.
Choice D reason: Lifting the walker as it is moved forward is acceptable for lightweight or rolling walkers, depending on the client’s strength and model. While sliding is preferred for standard walkers, lifting is not inherently unsafe, so intervention is unnecessary unless improper execution is observed.

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A nurse is caring for a client who asks for information about advance directives and states, “I want to make sure my wishes are respected.” Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who is experiencing preterm contractions and dehydration. Which of the following statements should the nurse make?

Correct Answer is C

Explanation

A charge nurse is supervising a newly hired nurse who is instructing a client about how to use a walker. For which of the following actions should the charge nurse intervene?

Correct Answer is B

Explanation

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