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 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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The client finding that necessitates immediate attention by the practical nurse (PN) is a client who is having bright red drainage from the rectum following a colonoscopy with polyp removal. Bright red rectal bleeding can indicate active bleeding and immediate intervention is required to assess the severity of the bleeding, control the bleeding if possible, and prevent further complications.
A. The older client with a blood pressure of 100/70 after receiving meperidine for pain may require further assessment, but it does not indicate an immediate life-threatening condition.
B. Pink urine draining from the indwelling urinary catheter following a transurethral prostatectomy may be expected due to the surgical procedure, but it should still be monitored.
D. Brown-green bile draining from a T-tube after cholecystectomy for cholelithiasis is also an expected finding.
Correct Answer is A
Explanation
The finding that is the highest priority for the PN to report to the charge nurse is the blood urea nitrogen (BUN) level of 75 mg/dL or 12.9 mmol/L. This result indicates an elevated BUN level, which can be indicative of impaired kidney function. In a client receiving chemotherapy, an elevated BUN level may suggest chemotherapy-induced nephrotoxicity or other kidney-related complications. Prompt reporting is crucial to ensure appropriate intervention and management of the client's kidney function.
B. While the platelet count of 135,000/mm3 or 135 x 109/L is slightly below the normal reference range, it does not pose an immediate life-threatening risk. However, it should still be monitored and reported to the healthcare team for ongoing assessment and evaluation.
C. Decreased deep tendon reflexes may be an expected side effect of certain chemotherapy medications or a manifestation of neurotoxicity. While this finding should be documented and monitored, it is not as urgent as the elevated BUN level.
D. Periodic nausea and vomiting are common side effects of chemotherapy, but they may also be indicative of other underlying issues such as dehydration, electrolyte imbalances, or gastrointestinal complications. While this finding should be addressed and managed, it is not the highest priority compared to the elevated BUN level.
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