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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Correct Answer is D
Explanation
Gently blowing the nose helps to clear any mucus or debris from the nasal passages, allowing for better delivery and absorption of the medication. It also helps to ensure that the nasal passages are clear and open, allowing the medication to reach its intended target.
A. Deep breathing and coughing are unrelated to the administration of nasal spray and are not necessary before using the medication.
B. Checking glucose levels before and after administration is not relevant for fluticasone furoate nasal spray. Glucocorticoid nasal sprays are not typically associated with significant effects on blood glucose levels.
C. Exhaling through the mouth is not a specific action required before using the nasal spray. It may be a general instruction for some other respiratory therapies or procedures, but it is not directly related to the administration of the nasal spray.
Correct Answer is B
Explanation
After a hip arthroplasty with prosthesis placement, it is important to follow specific precautions to protect the surgical site and prevent dislocation of the hip joint. One common precaution is to avoid excessive internal rotation, adduction, and f
The other observations mentioned in the scenario are correct and demonstrate appropriate knowledge of the turning procedure:
A. Placing an abduction pillow between the client's legs helps maintain proper alignment and prevents adduction of the legs, which can cause hip dislocation.
C. Keeping the back straight and knees bent when moving the client promotes proper body mechanics and reduces the risk of injury to the UAPs.
D. Using a turning sheet under the client for turning and repositioning helps reduce friction and shearing forces, making the process safer and more comfortable for the client.
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