A nurse is caring for a client who has named a person to serve as his health care proxy. The client states he needs clarification about this type of advance directive. Which of the following statements by the client indicates a need for clarification?

Correct Answer: C

Rationale: The correct answer is C because the statement "I have to choose a family member as my health proxy" is incorrect. The client does not have to choose a family member as their health care proxy; they can choose any trusted individual to act as their proxy. This indicates a need for clarification as the client may be under the misconception that the proxy must be a family member. Statement A is not the correct answer because the client can indeed change their designated health care proxy at any time. Statement B is not the correct answer because end-of-life choices are typically made by the proxy only if the client is unable to make decisions themselves. Statement D is not the correct answer because the health care proxy does go into effect as soon as it is designated, not only when the client is incapable of making decisions.

Correct Answer: B

Rationale: The correct answer is B: Another staff nurse provides testimony about how a reasonable, prudent nurse would have handled the situation. In a legal proceeding to determine if the nurse was negligent, the standard used is typically that of what a reasonable and prudent nurse would have done in the same situation. This standard is known as the "standard of care." It is important because it assesses the nurse's actions based on what is considered acceptable and appropriate within the nursing profession. Testimony from another staff nurse who can provide insight into how a reasonable and prudent nurse would have acted is crucial in establishing whether the nurse in question met this standard. Choice A is incorrect because testimony from an expert nurse about how the situation should have been handled differently may not necessarily reflect the standard of care for a reasonable and prudent nurse. Choice C is incorrect because the client's attorney stating that the injury could have been prevented does not establish the standard of care for a nurse in the situation. Choice D is incorrect because the client's provider

Correct Answer: D

Rationale: The correct answer is D: Right supervision. The nurse checking in with assistive personnel to ensure tasks are completed is an example of proper supervision, which is one of the rights of delegation. Supervision involves overseeing and guiding the work of others to ensure tasks are being carried out correctly and safely. This helps maintain accountability and quality of care. Summary of other choices: A: Right circumstances - This refers to ensuring the task is appropriate for delegation based on factors such as patient condition and complexity. B: Right communication - This involves clear and effective communication of tasks, responsibilities, and expectations between the nurse and assistive personnel. C: Right person - This focuses on selecting the most qualified and competent individual to perform the delegated task based on their skill level and training.

Correct Answer: B

Rationale: The correct answer is B. The nurse should assess the client who had an indwelling urinary catheter removed 5 hours ago and has not voided first. This is because urinary retention can lead to complications like urinary tract infection or bladder distention. It is important to monitor and address this promptly to prevent further issues. A: While a green gastric aspirate with a pH of 5.3 may indicate potential issues, it is not as urgent as urinary retention. C: A capillary refill time of 4 seconds in a client with COPD is concerning but does not require immediate attention compared to urinary retention. D: Fruity breath odor in a client with late-stage cirrhosis may indicate hepatic encephalopathy, which is serious, but urinary retention takes precedence due to the risk of immediate complications.

Correct Answer: C

Rationale: The correct answer is C because it demonstrates empathy and acknowledges the staff nurse's feelings of frustration. By expressing understanding and empathy towards the staff nurse's situation, the charge nurse validates their emotions and shows support. This can help in de-escalating the situation and fostering a positive working relationship. Option A focuses more on the staff nurse's behavior rather than addressing the issue at hand. Option B offers a solution but does not address the emotional aspect of the situation. Option D places the blame on the staff nurse for not informing ahead of time, which can be counterproductive in resolving the immediate issue. Ultimately, option C is the most appropriate response in this scenario as it shows empathy and understanding towards the staff nurse's feelings.