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. The LPN is auscultating for bowel sounds and hears between 3 and 4 bowel sounds per minute. This is a somewhat expected finding for which of these clients?

A. a 63-year-old female undergoing chemotherapy for breast cancer
B. a 56-year-old female with dementia undergoing a swallow study
C. a 34-year-old male with a PEG tube newly admitted for diabetic ketoacidosis
D. a 45-year-old male recovering from a knee replacement under general anesthesia

Correct answer: D

Rationale: When recovering from general anesthesia, hypoactive bowel sounds can be expected due to the effects of the anesthesia on gut motility. For the other clients, hearing less than 5 bowel sounds per minute would indicate an abnormal finding. In the context of the given situation, the client recovering from knee replacement surgery aligns with the expected range of bowel sounds post-general anesthesia. Therefore, choice D is the correct answer. Choices A, B, and C present scenarios where hearing less than 5 bowel sounds per minute would be abnormal, indicating potential issues that need further evaluation.

3. Which statement about clinical pathways is inaccurate?

A. They require daily updates.
B. They illustrate the expected client response to their diagnosis.
C. The objective is improvement or discharge from the facility.
D. They are evidence-based.

Correct answer: A

Rationale: The correct answer is that clinical pathways do not necessarily require daily updates. Clinical pathways can be customized to be updated daily, weekly, or at other intervals based on patient needs and facility protocols. Choice A is inaccurate as daily updates are not always mandatory for clinical pathways. Choices B, C, and D are accurate features of clinical pathways: they depict the expected client response to the diagnosis, aim for improvement or discharge, and are grounded in evidence-based practices to ensure optimal care.

4. What sign might the nurse observe in a client with a high ammonia level?

A. coma
B. edema
C. hypoxia
D. polyuria

Correct answer: A

Rationale: Coma is a sign that a nurse might observe in a client with a high ammonia level. Elevated ammonia levels can lead to hepatic encephalopathy, a condition characterized by impaired brain function, which can progress to coma. Edema (choice B) is swelling caused by excess fluid trapped in body tissues, not typically associated with high ammonia levels. Hypoxia (choice C) is a condition of inadequate oxygen supply to tissues and is not directly related to high ammonia levels. Polyuria (choice D) refers to excessive urination and is not a typical sign of high ammonia levels.

5. A nurse enters a client's room to administer a medication that has been prescribed by the health care provider. The client asks the nurse about the medication. Which response by the nurse is appropriate?

A. 'I know that it's for fluid buildup, and I think you've taken it before.''
B. 'It's called furosemide (Lasix), and it will promote urination and rid your body of the excess fluid. It can cause an alteration in electrolyte levels, so we'll need to increase the potassium in your diet.''
C. 'It's to help get rid of the swelling in your feet.''
D. ''You need to discuss this medication with your health care provider.''

Correct answer: B

Rationale: A client has the right to be informed of the medication name, purpose, action, and potential undesirable effects of a prescribed medication. The nurse should provide adequate information to the client. Choice B is the correct answer as it includes the medication name, its purpose (promoting urination and eliminating excess fluid), and a potential side effect (alteration in electrolyte levels) with a plan for managing it (increasing potassium in the diet). This response demonstrates thorough and complete information. Choice A provides some information but lacks details on potential side effects and dietary adjustments. Choice C is vague and does not provide specific details about the medication. Choice D deflects the client's question and does not fulfill the client's right to information.