A nurse is teaching a newly licensed nurse about advance directives. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"A health care surrogate must be a family member."

"The client can resume control of health care after a temporary loss of competency."

"The provider will choose a client's health care surrogate."

"The provider can go against the client's wishes regarding advance directives."

Answer and Explanation

The Correct Answer is B

A. "A health care surrogate must be a family member.": This statement is incorrect. A health care surrogate, also known as a health care proxy or agent, does not necessarily have to be a family member. It can be any individual chosen by the client to make health care decisions on their behalf if they become unable to do so.
B. "The client can resume control of health care after a temporary loss of competency.": This statement demonstrates an understanding of advance directives. Advance directives allow individuals to maintain control over their health care decisions by specifying their preferences for treatment or appointing a surrogate decision-maker. If a client experiences a temporary loss of competency, they can regain control of their health care decisions once competency is restored.
C. "The provider will choose a client's health care surrogate.": This statement is incorrect. It is the responsibility of the client to choose their health care surrogate. While healthcare providers may provide guidance and information about advance directives, they do not choose the surrogate for the client.
D. "The provider can go against the client's wishes regarding advance directives.": This statement is incorrect. Advance directives are legally binding documents that express a client's wishes regarding medical treatment. Healthcare providers are generally obligated to follow the directives outlined in these documents, and they cannot go against the client's wishes unless certain legal exceptions apply, such as emergency situations where immediate action is required to preserve life.

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Correct Answer is B

Explanation

A. Hypertension:
Disulfiram does not typically cause hypertension as an adverse effect. However, consuming alcohol while taking disulfiram can lead to a range of cardiovascular effects, including hypotension rather than hypertension.

B. Headache:
Consuming alcohol while taking disulfiram can result in a severe and rapid onset of symptoms known as the disulfiram-alcohol reaction. Headache is a common symptom of this reaction, along with flushing, nausea, vomiting, and palpitations. Therefore, monitoring for headaches is essential in clients taking disulfiram who report alcohol ingestion.

C. Insomnia:
Insomnia is not a commonly reported adverse effect of disulfiram. The disulfiram-alcohol reaction primarily involves physical symptoms rather than disturbances in sleep patterns.

D. Tinnitus:
Tinnitus, or ringing in the ears, is not a typical adverse effect of disulfiram. However, disulfiram can cause a range of neurological symptoms as part of the disulfiram-alcohol reaction, but tinnitus is not commonly reported.

A. Instruct a client on the use of an incentive spirometer. B. Insert an NG tube for a client who requires enteral feedings. C. Obtain a client's vital signs every 4 hr. D. Record a client's intake after each meal, E. Transfer a client to physical therapy.

Correct Answer is ["C","D","E"]

Explanation

C. Obtain a client's vital signs every 4 hr:
This task can typically be delegated to assistive personnel (AP) who have been trained and deemed competent in measuring vital signs. Routine monitoring of vital signs, such as temperature, pulse, respirations, and blood pressure, is within the scope of practice for AP and does not require the specialized skills of a licensed nurse.

D. Record a client's intake after each meal:
Assistive personnel can be delegated the task of recording a client's intake after each meal. This involves documenting the amount and type of food and fluids consumed by the client. While assessment of intake may involve some judgment, AP can be trained to perform this task accurately and consistently.

E. Transfer a client to physical therapy:
Assistive personnel can assist with transferring clients to physical therapy sessions. This may include tasks such as assisting clients into a wheelchair or onto a stretcher and accompanying them to the therapy area. While ensuring client safety during transfers is crucial, AP can perform these tasks under the direction and supervision of licensed nursing staff or physical therapists.

A. Instruct a client on the use of an incentive spirometer:
Teaching clients how to use medical equipment, such as an incentive spirometer, typically requires specialized knowledge and skills that fall within the scope of practice of licensed nursing staff. Therefore, this task should not be delegated to assistive personnel.

B. Insert an NG tube for a client who requires enteral feedings:
Inserting an NG tube is a specialized nursing skill that requires training, expertise, and an understanding of anatomy, proper technique, and potential complications. This task should only be performed by licensed nursing staff, such as registered nurses (RNs) or licensed practical nurses (LPNs), who have received appropriate education and training.

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A nurse is teaching a newly licensed nurse about advance directives. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is taking disulfiram for alcohol use disorder and reports ingestion of alcohol. For which of the following adverse effects should the nurse monitor?

Correct Answer is B

Explanation

A nurse is planning assignments for the upcoming shift. Which of the following tasks should the nurse delegate to an assistive personnel? (Select all that apply.)

Correct Answer is ["C","D","E"]

Explanation

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