A nurse is caring for a client who wants to stop receiving treatment for terminal cancer. The client's family asks the nurse if it is possible to continue the treatment without the client's knowledge. Which of the following responses should the nurse make?

"Your family member has the right to refuse care."

"To continue treatment, you must be appointed as your family member's health care surrogate."

"We should discuss different treatment options when your family member is not present."

"I can submit your request to the ethics committee."

Answer and Explanation

The Correct Answer is A

A. "Your family member has the right to refuse care." Every competent adult has the legal and ethical right to make decisions about their own medical treatment, including the right to refuse care, even if it results in death.
B. "To continue treatment, you must be appointed as your family member's health care surrogate." The client is still competent and capable of making their own decisions, so a surrogate is not necessary or legally allowed to override their wishes.
C. "We should discuss different treatment options when your family member is not present." Discussing medical decisions behind the client’s back would be unethical and violate the principle of autonomy.
D. "I can submit your request to the ethics committee." There is no ethical dilemma here, as the client has the right to refuse treatment, and their decision must be respected.

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Correct Answer is D

Explanation

A. "Apply intermittent suction for 20 to 30 seconds." –
Suctioning should be applied intermittently for no more than 10 to 15 seconds to prevent hypoxia and mucosal damage.
B. "Place the catheter in a location that is clean and dry for later use." –
A suction catheter should not be reused once it has been used; it should be discarded after a single use to prevent infection.
C. "Hold the suction catheter with the clean, nondominant hand." –
The dominant hand should remain sterile and be used to control the suction catheter, while the nondominant hand is used to handle nonsterile equipment.
D. "Use surgical asepsis when performing the procedure." –
Nasotracheal suctioning is a sterile procedure because it involves direct access to the lower airway, requiring surgical asepsis to reduce the risk of infection.

A. Client is difficult to arouse B. Respiratory rate 10/min C. Pulse oximetry 88% on room air (95% to 100%) D. Blood pressure 99/46 mm Hg

Correct Answer is ["A","B","C"]

Explanation

Client is difficult to arouse – This is concerning and may indicate opioid overdose or sedation due to the recent administration of morphine. The nurse should assess the client's level of consciousness closely and consider reversal of the opioid (naloxone) if the client's level of sedation is excessive.

Respiratory rate 10/min – This is below the normal respiratory rate (12–20 breaths/min) and could indicate respiratory depression, a common side effect of opioids like morphine. Close monitoring and possible intervention are required.

Pulse oximetry 88% on room air (95% to 100%) – The oxygen saturation is low, which could indicate hypoxemia. The nurse should administer supplemental oxygen and notify the provider.

Other Findings:

Pupils are 3 mm, equal, and reactive to light – This is a normal finding and not concerning for opioid overdose.

Blood pressure 99/46 mm Hg – This is slightly lower than normal but not critically low, considering the client's condition. Morphine can cause hypotension, especially in older adults or hypovolemic clients.

Heart rate 61/min – This is within a normal range for some postoperative patients, especially in a restful state.

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A nurse is caring for a client who wants to stop receiving treatment for terminal cancer. The client's family asks the nurse if it is possible to continue the treatment without the client's knowledge. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to perform nasotracheal suctioning for a client. Which of the following is an appropriate action for the nurse to take?

Correct Answer is D

Explanation

Correct Answer is ["A","B","C"]

Explanation

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