A male client with a chronic medical condition tells the practical nurse (PN) that he wants no heroics to prolong his life if anything should happen to him. Which action should the PN take?
Place a "Do Not Resuscitate" sign outside the client's door and at the bedside.
Reassure the client that life-saving measures will not be taken without consent.
Complete an advance directive form and place it in the medical record.
Notify the client's healthcare provider of the client's wishes as soon as possible.
The Correct Answer is D
A. "Place a 'Do Not Resuscitate' sign outside the client's door and at the bedside."
A DNR order must be written by the healthcare provider and documented in the medical record. A sign alone is not sufficient to ensure the client’s wishes are followed.
B. "Reassure the client that life-saving measures will not be taken without consent."
While reassuring the client is important, the client’s wishes must be documented formally through an advance directive, which is legally binding and ensures that medical staff are aware of and follow the client’s instructions.
C. "Complete an advance directive form and place it in the medical record."
While completing an advance directive is important, the first priority is notifying the healthcare provider so that the client’s wishes can be documented and the proper legal forms can be completed.
D. "Notify the client's healthcare provider of the client's wishes as soon as possible."
The nurse should immediately notify the healthcare provider of the client’s wishes. The healthcare provider can then initiate the appropriate legal documentation, such as a DNR order or an advance directive, ensuring the client’s wishes are respected in the future. This is the first step in ensuring that the client’s preferences are followed.
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Related Questions
Correct Answer is C
Explanation
The client's complaint of a leg cramp suggests the possibility of a muscle cramp or spasm, which is a common occurrence during labor. Extending the leg and flexing the foot helps stretch and relax the affected muscle, which can alleviate the cramp. This intervention helps relieve the muscle spasm and promotes increased blood circulation to the area, potentially reducing the intensity and duration of the cramp.
A. Elevating the leg above the heart is not necessary for relieving a leg cramp. It may be helpful in certain situations, such as in the case of venous insufficiency or swelling, but it is not the First-line intervention for a leg cramp.
B. Massaging the calf and foot can be beneficial in relieving a leg cramp. However, the initial action should be to extend the leg and flex the foot to actively stretch the affected muscle. If the cramp persists or if additional comfort measures are needed, then the PN may consider massaging the calf and foot.
D. Checking the pedal pulse in the affected leg is not directly related to relieving a leg cramp. It may be a relevant assessment in certain situations, such as suspected circulatory compromise or deep vein thrombosis, but it is not the primary intervention for a leg cramp.
Correct Answer is C
Explanation
- Medication administration is a process that involves prescribing, dispensing, and giving medications to patients. It is a critical and complex task that requires accuracy, safety, and adherence to the rights of medication administration, such as the right patient, right drug, right dose, right route, right time, right documentation, and right response.
- When a male client tells the practical nurse (PN) that the pill he has been taking at home is a different color and size than the one the PN is trying to give him now, this may indicate a potential medication error
or discrepancy. A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm. A medication discrepancy is any difference between the current and previous medication regimens of a patient.
- The PN should respond to the client's concern by telling him that the PN will verify that the dispensed medication is a valid prescription. This means that the PN will check the medication label, the medication order, and the medication administration record (MAR) to confirm that the medication given to the client matches the one prescribed by the healthcare provider. The PN will also compare the dispensed medication with a drug reference guide or a picture of the medication to ensure that it is the correct drug and dosage form. The PN will also report any suspected errors or discrepancies to the healthcare provider or the pharmacy for clarification or correction.
- Options A, B, and D are incorrect answers, as they do not reflect the appropriate or responsible actions for the PN to take when faced with a possible medication error or discrepancy.
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