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.

Answer and Explanation

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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Correct Answer is D

Explanation

Dry mucous membranes and a dry mouth are common side effects of anticholinergic drugs like dicyclomine. These medications block the action of acetylcholine, a neurotransmitter responsible for stimulating secretions in the body. As a result, the client may experience dryness in various parts of the body, including the mouth.
Providing oral care, such as offering the client sips of water or providing a moistening agent for the mouth, can help alleviate the discomfort caused by dryness and promote oral hygiene. It is an appropriate and immediate intervention for the client's current symptoms.
Incorrect:
A. Checking vital signs may not directly address the client's dry mouth, but it is a good practice to assess the client's overall condition.
B. Monitoring hemoglobin would not be necessary in this situation, as it does not directly relate to the client's dry mucous membranes.
C. Notifying the charge nurse may be appropriate if the client's symptoms worsen or if there are other concerning factors, but the priority action in this case is to provide oral care to address the client's discomfort.

A. Maximize resting and avoid undue pressure on the cesarean incision. B. Return the patient to bed and maintain bed rest until the local ﬂow stabilizes. C. Adjust IV ﬂuid flow rate and continue to monitor the local ﬂow amount. D. Withhold bladder emptying until the Foley catheter is removed and contract the fundus.

Correct Answer is B

Explanation

The patient experienced a sudden guard while being assisted to the bathroom, which led to their hospitalization. The most appropriate action for the practical nurse (PN) in this situation is to prioritize the patient's safety and well-being. Returning the patient to bed and maintaining bed rest allows for stability and minimizes the risk of further complications or injury. By providing a safe and controlled environment, the PN can monitor the patient's condition and collaborate with the healthcare team to determine the appropriate course of action moving forward.

Options a), c), and d) are not relevant or appropriate in this context.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with irritable bowel syndrome (IBS) is receiving dicyclomine, an anticholinergic drug. Prior to administering the next dose, the practical nurse (PN) determines that the client's mucous membranes are dry, and the client reports having a dry mouth. Which action should the PN take

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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