A nurse on a medical unit is planning care for several clients.
Which of the following clients should benefit MOST from the nurse acting as an advocate?
An older adult client who has no family and is uncertain about moving to assisted living.
A client who makes an informed decision not to participate in chemotherapy treatment.
A client who has previously undergone a procedure that is to be performed for a second time.
A client who has been educated on treatment options and chooses alternative treatments.
The Correct Answer is A
Choice A rationale
An older adult client without family support who is uncertain about a significant life change like moving to assisted living is particularly vulnerable. The nurse advocate can help this client understand their options, express their concerns, and ensure their wishes are considered, as they may lack the resources or confidence to navigate this process independently, making advocacy crucial for their well-being and autonomy.
Choice B rationale
A client who makes an informed decision to refuse chemotherapy is exercising their autonomy. While the nurse supports this decision, the client is already empowered and making their own choices based on understanding, thus requiring less direct advocacy in the sense of ensuring their voice is heard or their rights are upheld against potential opposition.
Choice C rationale
A client undergoing a repeat procedure is likely familiar with the process and has presumably consented previously. While the nurse ensures they are still informed and comfortable, the need for strong advocacy to ensure their wishes are respected against external pressures is less pronounced compared to a vulnerable client facing a new and uncertain situation.
Choice D rationale
A client who chooses alternative treatments after being educated on conventional options is also exercising their autonomy based on their values and understanding. The nurse's role is to ensure this decision is informed, but the client is already acting as their own advocate by making a conscious choice, reducing the immediate need for external advocacy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The nurse practice act and agency policy provide the legal and organizational framework for nursing practice and delegation. Determining if the delegation of topical medication administration is permissible under these guidelines is the foundational first step to ensure legality and adherence to established protocols.
Choice B rationale
Assessing the UAP's training is crucial for safe delegation, but it's secondary to ensuring that the task is delegable in the first place according to legal and policy guidelines. Training is irrelevant if the task cannot be delegated.
Choice C rationale
Ensuring appropriate supervision is essential for delegated tasks, but again, it's contingent on whether the task can be legally and organizationally delegated. Supervision protocols come into play after the initial permissibility of delegation is established.
Choice D rationale
Evaluating the client's past response to the treatment is important for ongoing care but doesn't determine the initial delegability of the task to a UAP. The focus of the first question is on the legal and policy aspects of delegation. .
Correct Answer is A
Explanation
Choice A rationale
Before delegating any nursing task, the nurse must first determine if the action is permissible under the state's nurse practice act and the employing agency's policies. These regulations define the scope of practice for nurses and the tasks that can be safely and legally delegated to unlicensed personnel. If delegation is not allowed by these governing bodies, the subsequent questions become irrelevant.
Choice B rationale
While it is crucial to ensure that the UAP has been adequately trained and is competent to perform the delegated task safely and correctly, this consideration comes after establishing the legality and permissibility of the delegation according to the nurse practice act and agency policy. Training is important for safe implementation but not the initial determining factor.
Choice C rationale
Appropriate supervision is necessary when delegating tasks to UAPs to ensure client safety and provide guidance. However, the ability to delegate the task itself must first be established by legal and policy guidelines. Supervision is a component of safe delegation but not the primary question determining if delegation is even an option.
Choice D rationale
Evaluating the client's past response to a treatment might inform how the task is performed or any specific observations needed, but it does not determine the fundamental question of whether the task can be delegated to a UAP in the first place. Legal and policy frameworks dictate the scope of delegation, regardless of the client's history. .
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