which of the following is true of advanced directives

NCLEX-PN

Nclex PN Questions and Answers

1. Which of the following is true of advanced directives?

A. They should be appropriately documented in the client's chart.
B. They are only applicable if the client has a terminal illness.
C. They are required if the client is unconscious.
D. They are non-legal requests.

Correct answer: A

Rationale: The correct answer is that advanced directives should be appropriately documented in the client's chart. Advanced directives are legal requests regarding a client's healthcare that come into effect under specific circumstances, regardless of the severity of their illness or level of consciousness. Choice B is incorrect because advanced directives can cover various healthcare decisions, not just terminal illnesses. Choice C is incorrect as advanced directives can be established and documented while the client is conscious, not only if they are unconscious. Choice D is incorrect because advanced directives are indeed legal requests, not non-legal requests.

2. While assisting a healthcare provider in assessing a hospitalized client, the healthcare provider is paged to report to the recovery room. The healthcare provider instructs the nurse verbally to change the solution and rate of the intravenous (IV) fluid being administered. What is the most appropriate nursing action in this situation?

A. Calling the nursing supervisor to obtain permission to accept the verbal prescription
B. Asking the healthcare provider to write the prescription in the client's record before leaving the nursing unit
C. Telling the healthcare provider that the prescription will not be implemented until it is documented in the client's record
D. Changing the solution and rate of the IV fluid per the healthcare provider's verbal prescription

Correct answer: B

Rationale: Verbal prescriptions should be avoided due to the risk of errors. If a verbal prescription is necessary, it should be promptly written and signed by the healthcare provider, typically within 24 hours. Following agency policies and procedures regarding verbal prescriptions is crucial. In this scenario, the most appropriate nursing action is to request the healthcare provider to document the prescription in the client's record before leaving the unit. Calling the nursing supervisor to accept the verbal prescription without documentation, telling the healthcare provider to delay treatment until documented, and directly changing the IV fluid based on verbal orders all pose risks and do not align with best practices in medication administration.

3. When ambulating a client with right-sided weakness, a nursing assistant should be positioned on which side of the client?

A. Stands behind the client
B. Positions the free hand on the client's shoulder
C. Stands on the right side of the client
D. Grasps the security belt in the midspine area of the small of the client's back

Correct answer: C

Rationale: When ambulating a client with right-sided weakness, the nursing assistant should stand on the affected side, which in this case is the client's right side. This position allows the assistant to provide proper support and assistance. Standing behind the client (Choice A) is incorrect as the assistant should be on the affected side. Positioning the free hand on the client's shoulder (Choice B) is a correct action as it helps in pulling the client toward them in case of a forward fall. Grasping the security belt in the midspine area of the small of the client's back (Choice D) is also correct to provide support and stability during ambulation.

4. Which of the following lab values is associated with a decreased risk of cardiovascular disease?

A. high HDL cholesterol
B. low HDL cholesterol
C. low total cholesterol
D. low triglycerides

Correct answer: A

Rationale: The correct answer is high HDL cholesterol. High HDL cholesterol levels are associated with a decreased risk of cardiovascular disease because HDL helps remove LDL cholesterol from the arteries, reducing plaque buildup. Low HDL cholesterol (choice B) is actually associated with an increased risk of cardiovascular disease. Low total cholesterol (choice C) or low triglycerides (choice D) are not indicators of a decreased risk of cardiovascular disease; in fact, extremely low total cholesterol levels may indicate other health issues.

5. A nursing student is assigned to care for a client who requires a total bed bath. When the student explains to the client that she is going to gather supplies to administer the bath, the client states, 'I don't want a bath. I've been up all night, and I'm clean enough.' The student reports the client's refusal to the nurse. Which action by the nurse is appropriate?

A. Telling the nursing student to persuade the client to have a bath so that the evening shift staff will not have to do it
B. Telling the nursing student to allow the client to rest
C. Telling the client that the refusal of care will be informed to the health care provider
D. Telling the nursing student to give the client the bath anyway

Correct answer: B

Rationale: The client has the right to refuse a treatment or procedure, and if the client does refuse, the nurse must respect the client's decision. Therefore, the nurse would allow the client to rest. Persuading the client to have a bath and giving the bath anyway are both inappropriate as they violate the client's rights. Informing the health care provider of the refusal of care can be discussed with the client if needed, but the immediate action should be to respect the client's wishes and allow them to rest.