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."

"As the health care surrogate, the client's partner can make this decision."

"We'll need to have the nursing supervisor review the client's advance directives."

Answer and Explanation

The Correct Answer is C

A. Contacting the provider may be part of the process, but it does not directly address the conflict between the family members' wishes and the health care surrogate's legal authority.
B. While the ethics committee can be a valuable resource in resolving disputes, it is not the first step in this situation, as the health care surrogate has the legal right to make decisions on behalf of the unconscious client.
C. The health care surrogate is legally designated to make health care decisions for the client when they are unable to do so themselves. This includes decisions about life-sustaining treatments such as a feeding tube.
D. Reviewing the client's advance directives is important, but it does not supersede the authority of the health care surrogate unless the directives explicitly limit the surrogate's decision-making power.

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Correct Answer is A

Explanation

A. Black tags are typically used for individuals who are deceased or expected to die imminently. The chances of survival for this patient are very minimal since the burn surface area is more than 50% with full thickness burns
B. Yellow tags are used for those who require observation but are not in immediate danger.
C. Red tags are for those with severe injuries who require immediate treatment but have a chance of survival.
D. Green tags are used for individuals with minor injuries or those who require minimal medical assistance.

A. A client who is 3 days postoperative following abdominal surgery is ready for discharge B. A client who has Alzheimer's disease and bacterial pneumonia with newly onset restlessness C. A client who is 24 hr postoperative following surgical reduction of a hip fracture and reports a pain level of 7 D. A client who is newly admitted with diabetes mellitus and whose fasting blood glucose level is 200 mg/dL

Correct Answer is B

Explanation

A. A client ready for discharge, if stable and prepared for discharge, does not require immediate assessment.
B. Restlessness in a client with Alzheimer's and bacterial pneumonia could indicate a change in condition, potentially signaling an urgent issue that needs immediate assessment.
C. While pain management is important, the sudden onset of restlessness in a client with cognitive impairment and pneumonia takes priority.
D. An elevated fasting blood glucose level in a newly admitted diabetic client requires attention but might not be as immediately critical as the acute change in behavior seen in option B.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

Explanation

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

Correct Answer is B

Explanation

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

A nurse in the emergency department is preparing to care for a client who arrived via ambulance. The client is disoriented and has a cardiac arrhythmia. Which of the following actions should the nurse take?

A nurse is assessing a client who is postoperative following a left leg below-the-knee amputation. Which of the following client statements indicates the potential need for a referral to an occupational therapist?

A nurse manager is leading a discussion about ethical dilemmas. Which of the following situations should the nurse manager include as an example of an ethical dilemma?

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 in the emergency department is performing triage for a group of clients who were in a train crash. Which of the following clients should the nurse tag as emergent?

To resolve a conflict between staff members regarding potential changes in policy, a nurse manager decides to implement the changes she prefers regardless of the feelings of those who oppose those changes. Which of the following conflict resolution strategies is the nurse manager using?

A nurse is caring for a client who has a new diagnosis of chlamydia. Which of the following actions should the nurse take?