A nurse is providing teaching to a client about advance directives. Which of the following client statements indicates to the nurse an understanding of the teaching?

"My health care surrogate should be my oldest living child."

"I can alter my advance directives later if I change my mind about treatment."

"My living will determine who speaks for me when I am unable to do so."

"Once my advance directives are signed, I no longer make my own decisions."

Answer and Explanation

The Correct Answer is B

Rationale:
A. A health care surrogate (or durable power of attorney for health care) does not have to be the oldest child; the client chooses the person they trust most to make decisions.
B. Advance directives are flexible and can be altered or revoked by the client at any time, as long as the client is competent.
C. A living will outlines the client’s treatment preferences, but it does not designate who will speak for the client. That role belongs to a health care proxy/surrogate.
D. Signing advance directives does not remove the client’s right to make decisions. The client retains autonomy as long as they are capable of decision-making.

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Correct Answer is ["A","B","E","F","H","I"]

Explanation

Rationale:
A. Hydration status: Nausea, vomiting, and limited oral intake put the client at risk for dehydration, requiring monitoring and possible intervention.
B. Heart rate: Increased from 80/min at 1730 to 102/min at 2300, indicating possible systemic stress or dehydration.
E. Headache: Client reports a severe headache (7/10), which can indicate systemic worsening or complications.
F. Temperature: Rose to 39° C (102.2° F), showing worsening infection.
H. Emesis: Client vomited 230 mL, which can contribute to fluid and electrolyte imbalance.
I. Blood pressure: Increased from 118/72 mm Hg to 152/92 mm Hg, suggesting possible stress response, pain, or early complications.

A. Client 3 at 1020 B. Client 4 at 1130 C. Client 4 at 0815 D. Client 1 at 0745 E. Client 4 at 0930 F. Client 1 at 1600 G. Client 4 at 0800 H. Client 4 at 1700 I. Client 2 at 1700 J. Client 1 at 1830

Correct Answer is ["A","B","D","F"]

Explanation

Rationale:
A. Obtaining a blood glucose for the newborn is within the PN’s scope of practice and can be safely delegated.
B. Performing a fundal check is a routine postpartum assessment that a PN can perform under supervision.
C. Conducting an initial newborn assessment requires RN-level assessment skills and cannot be delegated.
D. Reinforcing information about circumcision involves reinforcing teaching, which is within the PN’s scope.
E. Initiating a care plan for a new postpartum client requires nursing judgment and cannot be delegated.
F. Reinforcing safe sleep practices is teaching reinforcement, which a PN can perform.
G. Administering Vitamin K is a medication administration task requiring RN scope (depending on facility policy).
H. Reinforcing teaching about breastfeeding involves detailed education and assessment and should be performed by an RN.
I. Administering ibuprofen is medication administration and requires RN or authorized provider scope.
J. Providing discharge instructions and teaching requires RN-level assessment and teaching skills and cannot be delegated.

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A nurse is providing teaching to a client about advance directives. Which of the following client statements indicates to the nurse an understanding of the teaching?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client. Exhibits Which of the following 6 findings indicate the client's condition is worsening and need to be reported to the health care provider?

Correct Answer is ["A","B","E","F","H","I"]

Explanation

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Correct Answer is ["A","B","D","F"]

Explanation

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