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. How often should physical restraints be released?

A. Every 2 hours
B. Between 1 and 3 hours
C. Every 30 minutes
D. At least every 4 hours

Correct answer: A

Rationale: The correct answer is to release physical restraints every 2 hours. Releasing restraints every 2 hours helps prevent complications associated with prolonged immobilization. Releasing restraints every 30 minutes (choice C) may be too frequent and disruptive to the client's care. Releasing restraints between 1 and 3 hours (choice B) introduces variability that could lead to inconsistencies in care. Releasing restraints at least every 4 hours (choice D) does not adhere to the recommended frequency of every 2 hours.

3. Which of the following statements by a client with gastroesophageal reflux disease (GERD) indicates adequate understanding?

A. "I should eat right before bedtime."?
B. "I should eat large meals."?
C. "I should sit up after eating."?
D. "I should lie flat after eating."?

Correct answer: C

Rationale: The correct statement for a client with GERD is, 'I should sit up after eating.' This helps prevent reflux by keeping the stomach contents down. Choice A is incorrect as eating right before bedtime can exacerbate GERD symptoms by increasing the likelihood of reflux during the night. Choice B is incorrect because consuming large meals can lead to increased stomach pressure and worsen reflux symptoms. Choice D is incorrect because lying flat after eating can promote reflux due to gravity assisting the flow of stomach contents into the esophagus, worsening GERD.

4. When a drug is listed as Category X and prescribed to women of child-bearing age/capacity, the nurse and the interdisciplinary team should counsel the client that:

A. Pregnancy tests are not reliable while taking the drug.
B. She must use a reliable form of birth control.
C. She should not take the Category X drug on days she has intercourse.
D. She must follow up with an endocrinologist.

Correct answer: B

Rationale: When a drug is categorized as Category X, it signifies that there are significant risks of fetal abnormalities if taken during pregnancy. For this reason, women of child-bearing age/capacity should use reliable forms of birth control to prevent pregnancy while on the medication. This ensures that the client avoids the potential harm to the fetus. Option A is incorrect because pregnancy tests are not unreliable due to the drug, but rather the risk is related to potential harm to the fetus. Option C is incorrect as avoiding the drug only on days of intercourse does not provide sufficient protection against pregnancy. Option D is incorrect as the need for an endocrinologist is not directly related to the use of Category X drugs.

5. During shift change, a nurse is giving report to the oncoming LPN. Which of these is an inappropriate way to give shift report?

A. The nurse gives report to the oncoming LPN, checking a wound vac and dressing together.
B. The nurse reports in SBAR format, noting that the client was noncompliant with their diet during the shift.
C. The nurse reports in the hallway, in SBAR format, and alerts the oncoming LPN about how rude the client was throughout the shift.
D. The nurse reports at bedside with the oncoming LPN and discusses the client's concerns after the chart has been reviewed.

Correct answer: C

Rationale: The correct answer is 'The nurse reports in the hallway, in SBAR format, and alerts the oncoming LPN about how rude the client was throughout the shift.' This choice is inappropriate because shift report should be given at the bedside, in SBAR format, and in an objective way. It is important to maintain professionalism and focus on the client's condition and care needs, rather than personal opinions or subjective comments. Reporting in the hallway may compromise patient privacy and confidentiality. Choices A, B, and D demonstrate appropriate ways of giving shift report by focusing on relevant information, using SBAR format, and discussing client concerns after reviewing the chart, which promotes effective communication and continuity of care.