Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who is comatose. The client has a living will that declines the use of artificial enteral nutrition as a life-sustaining measure, but the client's family has requested that the staff begin tube feedings. Which of the following actions should the nurse take?
A. Insert the tube and begin feedings per the family's request.
Inserting the tube and beginning feedings per the family's request disregards the client's living will, which explicitly declines the use of artificial enteral nutrition as a life-sustaining measure. This action goes against the ethical principle of autonomy and could have legal implications.
B. Ask the provider to discuss the issue with the family.
While asking the provider to discuss the issue with the family could be a subsequent step, it is not the primary action to take in this situation. The nurse should first review the client's request with the family to emphasize the importance of the living will and facilitate understanding between the parties involved.
C. Report the dilemma to the facility's dietitian.
Reporting the dilemma to the facility's dietitian does not address the ethical and legal concerns at hand. The dietitian's role is to manage nutritional needs, not to resolve ethical dilemmas or interpret legal documents such as living wills. Involving the dietitian may not be helpful in addressing the conflict between the client's wishes and the family's request.
D. Review the client's request with the family.
Reviewing the client's request with the family respects the client's autonomy and the directives stated in their living will. It allows the nurse to communicate and clarify the client's wishes with the family, helping them understand the decisions made by the client when they were competent. This action promotes open communication and may facilitate resolution of the conflict.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN Leadership 2019 A Proctored Exam. Take the full exam now
Full Explanation
The correct answer is Choice D: Review the client's request with the family.
Choice D rationale: Reviewing the client's request with the family respects the client's autonomy and the directives stated in their living will. It allows the nurse to communicate and clarify the client's wishes with the family, helping them understand the decisions made by the client when they were competent. This action promotes open communication and may facilitate resolution of the conflict.
Choice A rationale: Inserting the tube and beginning feedings per the family's request disregards the client's living will, which explicitly declines the use of artificial enteral nutrition as a life-sustaining measure. This action goes against the ethical principle of autonomy and could have legal implications.
Choice B rationale: While asking the provider to discuss the issue with the family could be a subsequent step, it is not the primary action to take in this situation. The nurse should first review the client's request with the family to emphasize the importance of the living will and facilitate understanding between the parties involved.
Choice C rationale: Reporting the dilemma to the facility's dietitian does not address the ethical and legal concerns at hand. The dietitian's role is to manage nutritional needs, not to resolve ethical dilemmas or interpret legal documents such as living wills. Involving the dietitian may not be helpful in addressing the conflict between the client's wishes and the family's request.
Similar Questions
A case manager is planning an interprofessional conference for a client who is 3 days postoperative following an open reduction and internal fixation of the right hip. Which of the following concerns is the priority for discussion at the conference?
A. The client does not have transportation for discharge home.
The client does not have transportation for discharge home. Rationale: While transportation is important for discharge planning, it is not the priority concern in this situation. The client's immediate needs and well-being take precedence over transportation concerns.
B. The client refuses to attend physical therapy sessions.
The client refuses to attend physical therapy sessions. Rationale: The correct choice. After a hip surgery, physical therapy is crucial for preventing complications, promoting mobility, and ensuring optimal recovery. The refusal to attend these sessions could lead to delayed healing, increased risk of complications, and impaired functional outcomes. Addressing the client's resistance to therapy is a priority to ensure the best possible recovery.
C. The client's home health nurse has not completed the home assessment.
The client's home health nurse has not completed the home assessment. Rationale: While a home assessment is important for discharge planning, it is not the most immediate concern. The client's refusal to attend physical therapy could have more immediate and significant effects on their recovery and well-being.
D. The client describes feelings of depression after family visits.
The client describes feelings of depression after family visits. Rationale: While addressing the client's emotional well-being is important, it is not the priority concern in this situation. The refusal to attend physical therapy sessions could have physical consequences that take precedence over the emotional aspect.
Full Explanation
The correct answer is choice B.
Choice A rationale:
The client does not have transportation for discharge home. Rationale: While transportation is important for discharge planning, it is not the priority concern in this situation. The client's immediate needs and well-being take precedence over transportation concerns.
Choice B rationale:
The client refuses to attend physical therapy sessions. Rationale: The correct choice. After a hip surgery, physical therapy is crucial for preventing complications, promoting mobility, and ensuring optimal recovery. The refusal to attend these sessions could lead to delayed healing, increased risk of complications, and impaired functional outcomes. Addressing the client's resistance to therapy is a priority to ensure the best possible recovery.
Choice C rationale:
The client's home health nurse has not completed the home assessment. Rationale: While a home assessment is important for discharge planning, it is not the most immediate concern. The client's refusal to attend physical therapy could have more immediate and significant effects on their recovery and well-being.
Choice D rationale:
The client describes feelings of depression after family visits. Rationale: While addressing the client's emotional well-being is important, it is not the priority concern in this situation. The refusal to attend physical therapy sessions could have physical consequences that take precedence over the emotional aspect.
A nurse is developing a discharge plan for a client who is postoperative and will require a wheelchair in the home. The nurse should place a referral to which of the following resources to assist the client with this need?
A. Occupational therapy
Occupational therapy - This is incorrect because occupational therapy focuses on improving daily living and working skills, not providing wheelchairs.
B. Social services
Social services - This is the correct answer. Discharge planning begins at admission and should prepare for the functional ability of the client. This includes whether they have caregivers at home, or if they’re in need of one. A referral for social services can be made as needed to address gaps in the clients support system or resources.
C. Home health
Home health - This is incorrect because home health provides medical treatment, not equipment like wheelchairs.
D. Physical therapy
Physical therapy - This is incorrect because physical therapy helps improve mobility and strength, but does not provide wheelchairs.
Full Explanation
The correct answer is b. Social services.
Choice A: Occupational therapy - This is incorrect because occupational therapy focuses on improving daily living and working skills, not providing wheelchairs.
Choice B: Social services - This is the correct answer. Discharge planning begins at admission and should prepare for the functional ability of the client. This includes whether they have caregivers at home, or if they’re in need of one. A referral for social services can be made as needed to address gaps in the clients support system or resources.
Choice C: Home health - This is incorrect because home health provides medical treatment, not equipment like wheelchairs.
Choice D: Physical therapy - This is incorrect because physical therapy helps improve mobility and strength, but does not provide wheelchairs.
A nurse is caring for four clients. Which of the following assessment findings is the priority?
A. A client who has facial drooping following a stroke 8 hours ago.
A client who has facial drooping following a stroke 8 hours ago (Choice A) is a concern as it may indicate neurological damage; however, a client with a femur fracture experiencing shortness of breath takes priority due to the potential risk of a pulmonary embolism, a life-threatening complication.
B. A client who has a femur fracture and reports feeling short of breath.
A client who has a femur fracture and reports feeling short of breath (Choice B) is the priority assessment finding. Shortness of breath in this context raises concern for a possible pulmonary embolism, which is a critical condition that requires immediate intervention.
C. A client who had an appendectomy 12 hours ago and reports pain as 5 on a scale of 0 to 10.
A client who had an appendectomy 12 hours ago and reports pain as 5 on a scale of 0 to 10 (Choice C) is a valid concern, but it is of lower priority compared to a client with a femur fracture and respiratory distress.
D. A client who had an open cholecystectomy 4 days ago and has serosanguineous drainage on the wound dressing.
A client who had an open cholecystectomy 4 days ago and has serosanguineous drainage on the wound dressing (Choice D) is a normal postoperative finding and does not require immediate attention. While wound assessment is important, it is not the priority in this scenario.
Full Explanation
The correct answer is choice B: A client who has a femur fracture and reports feeling short of breath.
Choice A rationale:
A client who has facial drooping following a stroke 8 hours ago (Choice A) is a concern as it may indicate neurological damage; however, a client with a femur fracture experiencing shortness of breath takes priority due to the potential risk of a pulmonary embolism, a life-threatening complication.
Choice B rationale:
A client who has a femur fracture and reports feeling short of breath (Choice B) is the priority assessment finding. Shortness of breath in this context raises concern for a possible pulmonary embolism, which is a critical condition that requires immediate intervention.
Choice C rationale:
A client who had an appendectomy 12 hours ago and reports pain as 5 on a scale of 0 to 10 (Choice C) is a valid concern, but it is of lower priority compared to a client with a femur fracture and respiratory distress.
Choice D rationale:
A client who had an open cholecystectomy 4 days ago and has serosanguineous drainage on the wound dressing (Choice D) is a normal postoperative finding and does not require immediate attention. While wound assessment is important, it is not the priority in this scenario.