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?

"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."

"You should contact the provider about your wishes for your family member."

"You should speak with the facility's ethics committee about your concerns."

Answer and Explanation

The Correct Answer is B

As the healthcare surrogate, the partner is legally allowed to make decisions on behalf of the client. A healthcare surrogate is an individual upon whom the legal mandate is given to make healthcare decisions on behalf of the client in the event where the client lacks capacity to do so.

A. No further review of the advanced directives is necessary if the surrogate is known

C and D. If clearly stated, no further review by the facility committee or provider is needed as they undermine the role of the surrogate.

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Correct Answer is C

Explanation

the nurse should respect the client’s autonomy and wishes and inform of the provider

A. informed consent is used to accept treatment and not vice versa.

B. the nurse should not apply any form of pressure to make the client accept treatment.

D. The nurse should be empathetic. Being sympathetic is unprofessional

A. A client who has peripheral vascular disease and has an absent pedal pulse in the right foot B. A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary temperature of 38° C (101° F) C. A client who is postoperative following a laminectomy 12 hr ago and is unable to void D. A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV chemotherapy

Correct Answer is C

Explanation

Inability to void will cause bladder distention which is a common trigger to autonomic dysreflexia. Autonomic dysreflexia is an emergency as it leads to severe and sudden rise in blood pressure.

A. Peripheral vascular disease leads to decreased or absent blood flow to the distal extremities which is limb threatening. This client require review but not as urgent as A

B. Fever in an expected finding in an infectious process such as MRSA as part of the body’s response.

D. Newly diagnosed client with cancer requires emotional support before chemotherapy which is not an emergency.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care for a client who has terminal cancer and is refusing chemotherapy. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse on a medical-surgical unit is caring for four clients. The nurse should recognize that which of the following clients is the highest priority?

Correct Answer is C

Explanation

A nurse enters a client's room and notices a small fire in the bathroom trash can. The nurse removes the client from the room. Which of the following actions should the nurse take next?

Nurses on an inclient care unit are working to help reduce unit costs. Which of the following actions is appropriate to include in the cost- containment plan?

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A nurse is providing teaching to assistive personnel about the application of wrist restraints to a client. Which of the following instructions should the nurse include in the teaching?

A nurse is assessing pressure ulcers on four clients to evaluate the effectiveness of a change in wound care procedure. Which of the following findings indicates wound healing?

A charge nurse notices that staff nurses are having difficulty using new IV infusion pumps for medication administration. Which of the following is the priority action by the charge nurse?

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 on a medical surgical unit is caring for a group of clients with the assistance of a licensed practical nurse (LPN) and assistive personnel. Which of the following tasks should the nurse assign to the LPN?