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 C

The action that the practical nurse (PN) should take in this situation is to complete an advance directive form and place it in the client's medical record. Advance directives are legal documents that outline an individual's healthcare preferences and treatment decisions in the event that they become unable to communicate or make decisions for themselves. By completing an advance directive, the client's wishes regarding life-saving measures can be documented and honored.
A. Placing a "Do Not Resuscitate" sign outside the client's door and at the bedside is not sufficient documentation of the client's wishes. While it may serve as a visual reminder to healthcare providers, it is important to have the client's preferences clearly documented in their medical records through a formal advance directive.
B. Reassuring the client that life-saving measures will not be taken without consent is important for establishing trust and communication. However, it is essential to have the client's preferences formally documented to ensure that their wishes are respected and followed.
D. Notifying the client's healthcare provider of the client's wishes is an important step, but it should be done after completing the advance directive form. The advance directive will provide clear instructions to the healthcare team regarding the client's preferences, and the healthcare provider can review and acknowledge these wishes accordingly.

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Correct Answer is D

Explanation

A. C-reactive protein level:
C-reactive protein (CRP) is a marker of inflammation but does not specifically identify the causative organism of an infection. While elevated CRP can suggest infection or inflammation, it doesn't provide the necessary information for treatment.

B. Serum blood glucose (BG) level:
Serum blood glucose levels are important to monitor in diabetic patients because high glucose levels can impair healing and increase the risk of infection. However, it does not directly help identify the causative organism in this situation.

C. Serum albumin:
Serum albumin reflects nutritional status and can indicate malnutrition or poor wound healing. While it may be relevant for healing, it is not the most immediate test to evaluate for infection.

D. Culture for sensitive organisms:
Given the red, swollen wound with drainage and foul odor, a wound culture is the most appropriate first step to identify the specific infectious organism. This will guide the healthcare provider in selecting the most appropriate antibiotic treatment.

A. Fluid volume intake and output. B. Vital sign measurement. C. Volume of peripheral pulses. D. Incisional pain scale rating.

Correct Answer is B

Explanation

Monitoring the client's vital signs, including temperature, heart rate, respiratory rate, and blood pressure, is crucial to assess for any signs of infection or complications following surgery.
A. While fluid volume intake and output are important to monitor for overall hydration status, it is not the most immediate concern after reinforcing the dressing.
C. Similarly, assessing the volume of peripheral pulses is important to evaluate peripheral perfusion, but it may not be the highest priority at this time.
D. Incisional pain scale rating is important to assess the client's comfort and pain level, but it should be done after ensuring the security of the surgical dressing.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

The practical nurse (PN) finds a postoperative client lying in bed with an unsecured surgical dressing as seen in the picture. After reinforcing the dressing, which follow-up assessment is most important for the PN to implement?

Correct Answer is B

Explanation

Ancient is scheduled for a thoracentesis that will be done at the bedside. What should the practical nurse (PN) prepare before the healthcare provider arrives to perform the procedure?

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