NCLEX RN Test Bank Questions PDF

NCLEX RN Test Bank Questions PDF Related

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You are caring for a client at the end of life. The client tells you that they are grateful for having considered and decided upon some end of life decisions and the appointments of those who they wish to make decisions for them when they are no longer able to do so. During this discussion with the client and the client's wife, the client states that 'my wife and I are legally married so I am so glad that she can automatically make all healthcare decisions on my behalf without a legal durable power of attorney when I am no longer able to do so myself' and the wife responds to this statement with, 'that is not completely true. I can only make decisions for you and on your behalf when these decisions are not already documented on your advance directive.' How should you, as the nurse, respond to and address this conversation between the husband and wife and the end of life?

  • A. You should respond to the couple by stating that only unanticipated treatments and procedures that are not included in the advance directive can be made by the legally appointed durable power of attorney for healthcare decisions.
  • B. You should be aware of the fact that the wife of the client has a knowledge deficit relating to advance directives and durable powers of attorney for healthcare decisions and plan an educational activity to meet this learning need.
  • C. You should be aware of the fact that the client has a knowledge deficit relating to advance directives and durable powers of attorney for healthcare decisions and plan an educational activity to meet this learning need.
  • D. You should reinforce the wife's belief that legally married spouses automatically serve for the other spouse's durable power of attorney for health care decisions and that others than the spouse cannot be legally appointed while people are married
Correct Answer: C

Rationale: The client's statement reflects a misunderstanding that a spouse automatically assumes the role of durable power of attorney for healthcare decisions without a legal designation. The wife's response is correct in that an advance directive takes precedence, and a durable power of attorney is only effective for decisions not covered by the advance directive. The nurse should recognize the client's knowledge deficit and plan education to clarify the roles of advance directives and durable power of attorney, as stated in option C.

You may also like to solve these questions

What is the purpose of administering diphenhydramine before a blood transfusion?

  • A. To prevent urticaria
  • B. To avoid fever and chills
  • C. To enhance clotting factors
  • D. To expand the blood volume
Correct Answer: A

Rationale: The clinical indicators of urticaria are a rash accompanied by pruritus. Urticaria is a manifestation of a transfusion reaction when it occurs during a blood transfusion and is preventable by premedicating the client with an antihistamine, such as diphenhydramine. The remaining options are incorrect. Clients can also be premedicated with acetaminophen to help prevent fever and chills.

The nurse is caring for a client with a history of chronic obstructive pulmonary disease who is receiving oxygen therapy. Which of the following flow rates is most appropriate for this client?

  • A. 1-2 L/min via nasal cannula.
  • B. 4-6 L/min via face mask.
  • C. 8-10 L/min via non-rebreather mask.
  • D. 12-15 L/min via Venturi mask.
Correct Answer: A

Rationale: A flow rate of 1-2 L/min via nasal cannula is appropriate for COPD clients to avoid suppressing their hypoxic respiratory drive.

The nurse is obtaining a health history for a client with osteoporosis. The nurse should specifically ask the client about which of the following? Select all that apply.

  • A. Amount of alcohol consumed daily.
  • B. Use of antacids.
  • C. Dietary intake of fiber.
  • D. Use of Vitamin K supplements.
  • E. Intake of fruit juices.
Correct Answer: A, B

Rationale: Excessive alcohol consumption and frequent antacid use (which may contain aluminum, reducing calcium absorption) are risk factors for osteoporosis. Fiber, vitamin K, and fruit juices are less relevant.

What type of immunity occurs when a person has an infectious, communicable disease like the measles?

  • A. Adaptive immunity
  • B. Passive natural immunity
  • C. Active natural immunity
  • D. Active artificial immunity
Correct Answer: C

Rationale: Active natural immunity occurs when a person develops immunity after exposure to an infectious disease like measles, producing antibodies through natural infection.

A client with a history of type 1 diabetes mellitus is prescribed insulin detemir (Levemir). The nurse should explain that this insulin:

  • A. Is taken as needed for high blood sugar.
  • B. Provides a steady basal insulin level.
  • C. Should be mixed with short-acting insulin.
  • D. Is administered immediately before meals.
Correct Answer: B

Rationale: Insulin detemir provides a steady basal insulin level over 24 hours, used for long-term glucose control.

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