Advance Directives And Surrogate Decision-Making - NCLEX Rn

1. A 60-year-old client with cirrhosis is hospitalized and becomes obtunded due to hepatic encephalopathy. The client previously appointed a surrogate decision-maker, but the surrogate is on an international flight and unreachable; the provider recommends a time-sensitive procedure to control bleeding. Current assessment: blood pressure 92/58 mm Hg, heart rate 120/min, confused to painful stimuli only, active melena. How should the nurse proceed if the surrogate decision-maker is unavailable?
   Answer: Support the provider's urgent treatment plan and follow facility policy for emergency consent while continuing attempts to reach the surrogate This question tests understanding of advance directives and surrogate decision-making in time-sensitive procedures without surrogate access. The priority concern is respecting client autonomy and legal guidelines while managing emergencies. Supporting the provider's plan and following emergency consent policy aligns with these principles by allowing necessary interventions. Refusing preparation delays care; asking a non-surrogate is invalid; discharging is unsafe. The decision-making principle is emergency implied consent when surrogates are unavailable. This ensures timely treatment ethically. A transferable strategy is to document rationale and follow-up in urgent cases in nursing practice.
2. A 52-year-old client is admitted with septic shock and is intubated and sedated. The chart lists a surrogate decision-maker, but the phone number is disconnected and no other contacts are available. Current assessment: blood pressure 82/46 mm Hg on vasopressors, heart rate 128/min, temperature 39.4°C (102.9°F). How should the nurse proceed if the surrogate decision-maker is unavailable?
   Answer: Continue urgent, life-sustaining treatment as ordered and collaborate with the team to locate an appropriate decision-maker This question tests understanding of advance directives and surrogate decision-making when surrogates are unreachable in emergencies. The priority concern is respecting client autonomy and legal guidelines while providing life-sustaining care. Continuing urgent treatment and collaborating to locate a decision-maker aligns with these principles by balancing immediate needs with surrogate involvement. Stopping vasopressors risks harm; asking another family is inappropriate; having the manager sign lacks authority. The decision-making principle is implied consent in emergencies without directives. This allows stabilization while seeking proper authority. A transferable strategy is to follow emergency protocols and document efforts in nursing practice.
3. An 82-year-old client is admitted to a medical-surgical unit with pneumonia and dehydration. The client is alert and oriented, has a history of heart failure, and has no advance directive on file. Current assessment: temperature 38.3°C (100.9°F), blood pressure 146/78 mm Hg, heart rate 96/min, oxygen saturation 91% on 2 L/min nasal cannula. Which action is MOST appropriate for the nurse when discussing advance directives with the client?
   Answer: Explain the purpose of advance directives and offer to provide the hospital's forms for the client to review An alert, oriented client has the right and capacity to receive information about advance directives and to decide voluntarily. The nurse's best action is to explain what advance directives are and offer the hospital's forms, leaving the choice entirely with the client. Telling the client that a do-not-resuscitate order is recommended at this age is coercive and also confuses a DNR order with the broader advance-directive discussion; the nurse should not steer the decision. Asking the client's spouse to decide whether to complete an advance directive bypasses the client's autonomy; fatigue does not mean the client lacks decision-making capacity. Delaying the discussion until the pneumonia resolves is not indicated because the client is currently alert and oriented; postponing solely to avoid anxiety can cause a missed opportunity while the client is still able to participate. The correct response supports informed choice, not persuasion, delegation, or deferral.
4. A 61-year-old client with newly diagnosed heart failure is being discharged from the hospital and asks, "What is an advance directive?" The client is alert, has a supportive partner, and has no document on file. Current assessment: blood pressure 128/76 mm Hg, heart rate 84/min, mild ankle edema, denies chest pain. Which action is MOST appropriate for the nurse when discussing advance directives with the client?
   Answer: Provide a brief explanation and offer written information and community resources to complete forms if desired This question tests understanding of advance directives and surrogate decision-making in client education upon inquiry. The priority concern is respecting client autonomy and legal guidelines by providing accurate, voluntary information. Offering a brief explanation, written information, and resources aligns with these principles by facilitating informed choices without pressure. Dismissing as only for older adults is inaccurate; asking the partner to complete violates autonomy; instructing to sign DNR is coercive. The decision-making principle is that advance directives empower future care decisions. Nurses promote awareness proactively. A transferable strategy is to use teach-back methods for legal education in nursing practice.
5. A 76-year-old client is admitted with a gastrointestinal bleed and becomes confused after receiving sedation for an endoscopy. The client's chart includes a do-not-resuscitate order but does not address transfusions; the spouse says, "No blood products," but the client previously stated to staff, "Do whatever you can to help me recover." Current assessment: blood pressure 90/54 mm Hg, heart rate 118/min, pale, oriented to name only. What is the PRIORITY nursing action when a client's advance directive is unclear?
   Answer: Clarify the client's current wishes when possible and notify the provider of the conflict and missing details This question tests understanding of advance directives and surrogate decision-making when directives lack specificity. The priority concern is respecting client autonomy and legal guidelines by addressing ambiguities promptly. Clarifying the client's current wishes and notifying the provider aligns with these principles by resolving conflicts with available information. Refusing transfusions delays care; proceeding assumes refusal incorrectly; delegating to unlicensed personnel is inappropriate. The decision-making principle is to seek client input when possible for unclear directives. This ensures decisions reflect current values. A transferable strategy is to involve ethics teams for directive ambiguities in nursing practice.
6. A 73-year-old client with advanced chronic obstructive pulmonary disease is admitted for an exacerbation and is now confused due to carbon dioxide retention. The client previously named a nephew as surrogate decision-maker, but the nephew is traveling and cannot be reached for several hours. Current assessment: blood pressure 142/80 mm Hg, heart rate 108/min, respiratory rate 30/min, oxygen saturation 86% on 4 L/min nasal cannula, drowsy. How should the nurse proceed if the surrogate decision-maker is unavailable?
   Answer: Provide urgent respiratory support as ordered and continue efforts to reach the surrogate for non-emergency decisions This question tests understanding of advance directives and surrogate decision-making when surrogates are delayed in emergencies. The priority concern is respecting client autonomy and legal guidelines while addressing acute needs. Providing urgent support and continuing efforts to reach the surrogate aligns with these principles by ensuring care continuity. Canceling treatments risks harm; asking a roommate lacks authority; delegating to therapists is inappropriate. The decision-making principle is to provide stabilizing interventions in urgencies. This bridges gaps until surrogates are involved. A transferable strategy is to prioritize patient safety in time-sensitive ethical scenarios in nursing practice.
7. A 77-year-old client with chronic kidney disease is admitted with hyperkalemia and is intermittently confused. The client has an advance directive, but the document is difficult to interpret and does not clearly address dialysis decisions; the spouse states, "He never wanted machines," while the adult daughter states, "He wanted dialysis." Current assessment: blood pressure 138/74 mm Hg, heart rate 56/min, peaked T waves on telemetry, oriented to person only. What is the PRIORITY nursing action when a client's advance directive is unclear?
   Answer: Notify the provider of the urgent clinical findings and request clarification of goals of care while treating the hyperkalemia per protocol In this emergency, the client has bradycardia and peaked T waves, so hyperkalemia is immediately life-threatening. Because the advance directive is unclear and family members disagree about dialysis, the nurse's first duty is to address the unstable clinical status while getting direction from the provider about goals of care. Notifying the provider of the findings and treating hyperkalemia per protocol simultaneously satisfies both obligations. Delaying care until the whole family agrees is unsafe because waiting can worsen arrhythmias; family consensus is not required before emergency treatment. Asking the spouse to make a final decision is flawed because the spouse's authority as surrogate is not established and the daughter's account conflicts with the spouse's, so a unilateral family decision does not resolve the ambiguity. Assuming the client refused dialysis based on the spouse's word "machines" ignores the unclear document and the opposing account; a nurse cannot infer wishes from a single phrase. Thus, the priority is to stabilize the client and obtain provider clarification rather than act on an ambiguous family statement.
8. A 64-year-old client with pancreatic cancer is alert and completing paperwork to appoint a surrogate decision-maker. The client's adult daughter says, "I'll decide based on what I want for Mom." Current assessment: blood pressure 110/66 mm Hg, heart rate 98/min, reports fatigue and poor appetite. Which nursing response is MOST appropriate regarding the surrogate decision-maker's role?
   Answer: Teach that the surrogate should base decisions on the client's known wishes and values, not the surrogate's personal preferences This question tests understanding of advance directives and surrogate decision-making in clarifying surrogate responsibilities. The priority concern is respecting client autonomy and legal guidelines by educating on proper roles. Teaching that surrogates base decisions on client wishes aligns with these principles by preventing personal bias. Allowing changes if family disagrees undermines autonomy; advising against family surrogates is unhelpful; assuming automatic surrogacy is incorrect. The decision-making principle is substituted judgment to reflect client values. This ensures fidelity to autonomy. A transferable strategy is to correct misconceptions early in planning discussions in nursing practice.
9. A 62-year-old client is in the intensive care unit after a massive stroke and is unresponsive (Glasgow Coma Scale 5). Vital signs: temperature 98.6°F (37°C), heart rate 96/min, blood pressure 148/86 mm Hg, respirations 10/min on the ventilator, oxygen saturation 98%. A signed advance directive in the chart states the client does not want long-term life support if there is no meaningful recovery. The client's adult daughter insists the nurse "do everything" and refuses to allow withdrawal of ventilator support. What should the nurse do FIRST when the family member disagrees with the advance directive?
   Answer: Tell the daughter the team will follow the client's documented wishes and notify the provider of the conflict This question tests understanding of advance directives and surrogate decision-making, specifically how to respond when family members disagree with documented wishes. The priority concern is respecting client autonomy and following legal guidelines while maintaining therapeutic relationships. Option A is correct because it acknowledges the client's documented wishes take precedence over family preferences and ensures proper provider notification for conflict resolution. Option B is incorrect because it would override the client's advance directive; Option C is premature as legal intervention is not the first step; Option D inappropriately delays following the client's wishes. The key principle is that valid advance directives legally guide care decisions when clients cannot speak for themselves. When faced with family disagreement about advance directives, nurses should first affirm the client's documented wishes, notify the provider, and facilitate communication while following facility policies.
10. A 74-year-old client with advanced dementia is admitted from a long-term care facility with sepsis. The client has a written advance directive requesting comfort-focused care only, but the client's daughter demands transfer to the intensive care unit and aggressive treatment. Current assessment: temperature 39.1°C (102.4°F), blood pressure 86/50 mm Hg, heart rate 124/min, lethargic and nonverbal. What should the nurse do FIRST when the family's wishes conflict with the client's advance directive?
    Answer: Explain that the client's advance directive guides care and notify the provider of the documented wishes This question tests understanding of advance directives and surrogate decision-making in conflicts with family wishes. The priority concern is respecting client autonomy and legal guidelines by upholding a valid directive for comfort care. Explaining that the advance directive guides care and notifying the provider aligns with these principles by prioritizing the client's documented preferences over family demands. Arranging a family meeting delays action; preparing for ICU transfer ignores the directive; calling risk management is unnecessary if the directive is clear. The decision-making principle is that advance directives supersede family opinions when explicit. Nurses must communicate this compassionately to de-escalate conflicts. A transferable strategy is to reference policies and involve palliative care for end-of-life ethical issues in nursing practice.
11. A 79-year-old client with advanced dementia is admitted with aspiration pneumonia. The client's advance directive requests no antibiotics and comfort-focused care; the client's son states, "Give antibiotics; Mom would want to live." Current assessment: temperature 38.6°C (101.5°F), blood pressure 102/60 mm Hg, heart rate 110/min, nonverbal and does not follow commands. What should the nurse do FIRST when the family member disagrees with the advance directive?
    Answer: Review the documented advance directive and notify the provider that the client requested no antibiotics, while supporting the son emotionally This question tests understanding of advance directives and surrogate decision-making in antibiotic refusal conflicts. The priority concern is respecting client autonomy and legal guidelines by upholding the no-antibiotics request. Reviewing the directive and notifying the provider while supporting the son aligns with these principles by honoring documented wishes compassionately. Administering antibiotics ignores the directive; asking for proof escalates; refusing discussion avoids advocacy. The decision-making principle is that directives guide palliative care preferences. Nurses balance enforcement with empathy. A transferable strategy is to involve social work for family support in ethical conflicts in nursing practice.
12. A 54-year-old client with metastatic cancer is admitted for uncontrolled pain and dehydration. Assessment: drowsy but arousable, blood pressure 98/60 mm Hg, heart rate 112/min, respirations 18/min, oxygen saturation 95% on room air. The chart lists the client's spouse as the health care surrogate, but the spouse cannot be reached by phone. The provider asks whether to start a feeding tube because the client is not eating. How should the nurse proceed if the surrogate decision-maker is unavailable?
    Answer: Continue attempts to reach the listed surrogate and notify the provider of the inability to obtain surrogate input before non-emergent decisions This question tests understanding of advance directives and surrogate decision-making when the designated surrogate is unavailable. The priority concern is respecting the client's right to have their chosen surrogate involved in non-emergent decisions while ensuring appropriate care. Option C is correct because it maintains efforts to reach the designated surrogate and involves the provider, respecting the legal hierarchy of decision-makers for non-urgent interventions. Option A is incorrect because it bypasses the designated surrogate; Option B inappropriately makes irreversible decisions without surrogate input; Option D is premature and unnecessary for non-emergent situations. The principle is that non-emergent decisions should involve the designated surrogate whenever possible, and providers should be notified when surrogates cannot be reached. For non-urgent decisions when surrogates are unavailable, continue attempts to contact them while collaborating with the healthcare team to determine appropriate interim measures.
13. An 80-year-old client is admitted from assisted living after a fall with a hip fracture. The client is alert and oriented and has no advance directive; the client's son says, "Don't talk to my mom about end-of-life stuff." Current assessment: blood pressure 150/82 mm Hg, heart rate 90/min, pain 8/10, oxygen saturation 95% on room air. Which action is MOST appropriate for the nurse when discussing advance directives with the client?
    Answer: Assess the client's readiness and provide information privately, since the client is capable of making decisions This question tests understanding of advance directives and surrogate decision-making when family restricts discussions. The priority concern is respecting client autonomy and legal guidelines by ensuring private access to information. Assessing readiness and providing information privately aligns with these principles by honoring the competent client's right to decide. Respecting the son's request violates autonomy; asking the son to decide shifts authority; waiting until after surgery misses preoperative opportunities. The decision-making principle is client self-determination for capable individuals. Nurses must facilitate confidential discussions. A transferable strategy is to prioritize privacy in ethical conversations in nursing practice.
14. A 73-year-old client with advanced heart failure is in the emergency department with severe shortness of breath. Assessment: cannot speak full sentences, oxygen saturation 82% on nonrebreather mask, heart rate 132/min, blood pressure 168/92 mm Hg. The client has a documented DNR order and an advance directive requesting no intubation, but the client's spouse is crying and demands intubation immediately. What should the nurse do FIRST when a family member disagrees with the advance directive?
    Answer: Inform the provider of the documented wishes and advocate to follow the client's directive while providing comfort measures This question tests understanding of advance directives and surrogate decision-making during emergency situations when family members emotionally oppose documented wishes. The priority concern is respecting client autonomy while providing compassionate care during a crisis. Option B is correct because it advocates for following the client's documented wishes while ensuring comfort measures, balancing legal obligations with compassionate family support. Option A is inappropriate and potentially harmful to remove grieving family; Option C violates the client's explicit wishes; Option D escalates the situation unnecessarily. The principle is that even in emergencies, valid advance directives must be followed while supporting distressed family members with comfort measures and compassionate communication. During emotional crises when families oppose advance directives, nurses should advocate for client wishes, ensure comfort measures are maximized, provide emotional support to family, and involve appropriate team members for family support.
15. A 45-year-old client is in a coma after a motor vehicle crash and is on mechanical ventilation in the intensive care unit. An advance directive on file states the client does not want long-term life support if there is no meaningful recovery; the spouse says, "I can't let you stop the ventilator." Current assessment: blood pressure 132/76 mm Hg, heart rate 88/min, pupils equal and reactive, no purposeful response to pain. What is the PRIORITY nursing action when a client's advance directive is unclear about the current situation?
    Answer: Review the advance directive details and clarify the client's stated conditions and goals with the provider and care team This question tests understanding of advance directives and surrogate decision-making when the directive's applicability is ambiguous. The priority concern is respecting client autonomy and legal guidelines by clarifying unclear aspects. Reviewing the advance directive and clarifying with the provider and team aligns with these principles by ensuring accurate interpretation before decisions. Asking the spouse to decide immediately pressures them; requesting a psychiatric evaluation is inappropriate; stopping discussion avoids resolution. The decision-making principle is to seek clarification through interdisciplinary collaboration when directives are unclear. This promotes ethical care aligned with client goals. A transferable strategy is to use ethics consultations for ambiguous situations in nursing practice.
16. A 68-year-old client is admitted for acute heart failure exacerbation and is alert and oriented. The client has no advance directive and says, "I don't want to think about that." Current assessment: blood pressure 160/88 mm Hg, heart rate 96/min, shortness of breath on exertion, oxygen saturation 94% on 2 L/min nasal cannula. Which action is MOST appropriate for the nurse when discussing advance directives with the client?
    Answer: Acknowledge the client's feelings, explain that completing an advance directive is voluntary, and offer to revisit the topic later The client is alert and oriented and has not made an advance directive. When the client declines to discuss it, the nurse must respect that choice while keeping the door open. The correct action is to acknowledge the client's feelings, explain that advance directives are voluntary, and offer to revisit the topic later. This approach honors patient autonomy and avoids coercion. The other options are incorrect. Documenting that the client is refusing care because they declined the advance directive discussion misrepresents the situation; the client only refused that discussion, not all care. Insisting that the client complete the forms before further treatment is coercive and violates voluntariness. Asking the spouse to decide when the client is alert and oriented disregards the client's own decision-making capacity. Therefore, the nurse should respect the client's current preference and provide an opportunity to discuss it later.
17. A 77-year-old client with moderate dementia is admitted from a long-term care facility for aspiration pneumonia. Assessment: confused, intermittently follows commands, temperature 101.3°F (38.5°C), heart rate 110/min, blood pressure 100/58 mm Hg, oxygen saturation 90% on 2 L/min nasal cannula. The client has an advance directive requesting comfort-focused care only, but the client's son insists on transfer to the intensive care unit and "all possible treatments." What should the nurse do FIRST when the family member disagrees with the advance directive?
    Answer: Explain to the son that the advance directive guides care and notify the provider of the disagreement The client's advance directive requests comfort-focused care, and this documented wish continues to guide treatment even when a family member disagrees. The nurse's first action is to explain that to the son and notify the provider so the conflict can be addressed in a timely, coordinated way, such as a family conference or ethics consultation. Preparing the client for ICU transfer is wrong because it treats the son's request as overriding the advance directive; a surrogate's authority is limited by the client's documented wishes. Telling the son to obtain a court order is not the nurse's appropriate first step and wrongly suggests that a family member can change an advance directive through the courts. Asking the nurse assistant to obtain the son's signature is also incorrect: informed consent cannot be delegated to assistive personnel, and consent for aggressive treatment would contradict the comfort-focused directive. The nurse should uphold the directive, keep the son informed, and involve the provider early while continuing to provide comfort measures.
18. A 67-year-old client is in a coma after a motor vehicle crash and is receiving mechanical ventilation in the intensive care unit. Vital signs: temperature 99.1°F (37.3°C), heart rate 88/min, blood pressure 124/70 mm Hg, oxygen saturation 97% on the ventilator. The client's advance directive on file states they do not want cardiopulmonary resuscitation or prolonged life support if permanently unconscious. The client's brother demands full resuscitation "no matter what" and threatens to sue staff. What should the nurse do FIRST when a family member disagrees with the advance directive?
    Answer: Notify the charge nurse and follow facility policy to ensure the client's documented wishes are communicated and honored. Notify the charge nurse and follow facility policy is the first action because a valid advance directive on file controls the client's care, even when a family member threatens legal action. The nurse must activate the chain of communication and policy so the client's documented wishes are honored. Arranging a family meeting with the provider and case management is not wrong as a later step, but it is not the immediate first step and it implies that discussion may alter a document that already reflects the client's choices. Asking the brother to bring proof that he is the legal decision-maker misdirects attention; the client's directive is already on file, and a surrogate cannot override the client's stated wishes. Telling the brother that the nurse will follow the family's wishes to avoid conflict, even while documenting the request, violates the client's autonomy and the legal protections of advance directives. The only option that protects the client, follows policy, and begins the proper chain of communication is to notify the charge nurse and follow facility policy.
19. A 70-year-old client with end-stage renal disease is hospitalized with fluid overload. The client is alert, has no advance directive, and says, "My kids will handle it if something happens." Current assessment: blood pressure 168/92 mm Hg, heart rate 92/min, crackles at lung bases, 2+ edema. Which action is MOST appropriate for the nurse when discussing advance directives with the client?
    Answer: Provide information about naming a surrogate decision-maker and encourage the client to share wishes with family This question tests understanding of advance directives and surrogate decision-making for a client relying on family without formal designation. The priority concern is respecting client autonomy and legal guidelines by encouraging formal documentation. Providing information about naming a surrogate and encouraging sharing wishes aligns with these principles by promoting proactive planning. Telling the client the hospital chooses automatically is inaccurate; asking children to complete paperwork violates autonomy; documenting refusal ends education prematurely. The decision-making principle is that clients should designate surrogates to ensure wishes are honored. Nurses educate to facilitate this process. A transferable strategy is to assess readiness and provide tailored education for legal planning in nursing practice.
20. An 81-year-old client with heart failure is admitted to a medical-surgical unit for shortness of breath. Assessment: alert and oriented, oxygen saturation 92% on 2 L/min nasal cannula, heart rate 104/min, blood pressure 132/74 mm Hg; the client states, "I don't have any papers about end-of-life care." The client's son is at the bedside and asks what the hospital needs "to make decisions" if the client worsens. Which action is MOST appropriate for the nurse when discussing advance directives with a client?
    Answer: Provide information about advance directives and offer to contact social work to help the client complete forms if desired This question tests understanding of advance directives and surrogate decision-making, particularly the nurse's role in educating clients about advance care planning. The priority concern is respecting client autonomy while providing appropriate information and resources. Option B is correct because it offers education and support without coercion, respecting the client's right to choose whether to complete advance directives. Option A is incorrect because advance directives are not mandatory for admission; Option C inappropriately pressures the son to make immediate decisions; Option D incorrectly limits the nurse's role in advance directive education. The principle is that nurses should provide information about advance directives and facilitate completion if desired, but never pressure or mandate participation. When discussing advance directives, nurses should offer resources, respect client readiness, and involve appropriate team members like social work for assistance.

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