a nurse is caring for a client who requests information about advance directives which of the following responses should the nurse make
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ATI PN Comprehensive Predictor 2020 Answers

1. A nurse is caring for a client who requests information about advance directives. Which of the following responses should the nurse make?

Correct answer: C

Rationale: The correct response is C: 'It includes end-of-life care instructions.' An advance directive is a legal document that outlines a client's preferences for medical treatment and end-of-life care in case they are unable to communicate. Choice A is incorrect because an advance directive focuses on healthcare decisions, not funeral arrangements. Choice B is incorrect as organ donation is a separate process from advance directives. Choice D is incorrect as advance directives do not provide legal guardianship rights, but rather specify healthcare wishes.

2. A nurse assisting with a childbirth class is discussing nonpharmacological strategies used during labor. Which of the following statements by a client indicates an understanding of cutaneous stimulation?

Correct answer: A

Rationale: The correct answer is A: 'Apply counter-pressure for back pain.' Counter-pressure involves applying pressure to the lower back to alleviate pain during labor. This technique is a form of cutaneous stimulation, which can help with pain relief. Choice B, deep breathing exercises, is a form of relaxation technique and does not directly involve cutaneous stimulation. Choice C, visualizing the baby's head, is a mental imagery technique and does not involve physical stimulation of the skin. Choice D, massage therapy, is a tactile stimulation technique but is not specifically focused on back pain relief through counter-pressure.

3. What is an important consideration when administering a blood transfusion?

Correct answer: A

Rationale: The correct answer is to ensure the blood is compatible with the recipient's blood type. This is crucial to prevent transfusion reactions, which can be life-threatening. Choice B is incorrect because warming blood to body temperature is not a standard practice and may lead to hemolysis. Choice C is incorrect as blood products are carefully screened for clots before distribution. Choice D is incorrect because it is not necessary for the recipient to eat before a blood transfusion.

4. What term refers to the agreement to keep promises?

Correct answer: A

Rationale: The term 'fidelity' specifically refers to the agreement to keep promises. Fidelity in healthcare ethics emphasizes the importance of healthcare professionals keeping their commitments to patients. Choice B, 'Non-maleficence,' relates to the ethical principle of doing no harm. Choice C, 'Autonomy,' refers to respecting a patient's right to make decisions about their own healthcare. Choice D, 'Justice,' pertains to fairness and equality in the distribution of healthcare resources.

5. A nurse is observing an assistive personnel (AP) apply antiembolic stockings for a client. Which of the following actions by the AP demonstrates an understanding of how to perform this skill?

Correct answer: B

Rationale: The correct answer is B. Applying antiembolic stockings before the client gets out of bed is crucial as it helps prevent venous stasis and clot formation. Choice A is incorrect because stockings should be applied before the client gets out of bed. Choice C is incorrect as using lotion under the stocking can cause the stocking to slip. Choice D is incorrect because the stocking should be smooth and not bunched to prevent pressure points.

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