A nurse is admitting a client to the medical-surgical unit. The Patient Self-Determination Act requires the nurse to perform which of the following actions during the admission process?
Document in the client's medical record if the client has advance directives.
Ensure the client has an attorney to contact for assistance with end-of-life documents.
Provide end-of-life education if the client has a terminal illness.
Provide the client with a list of eligible individuals who can serve as a health care proxy.
The Correct Answer is A
A. The Patient Self-Determination Act (PSDA) requires health care facilities to ask clients about advance directives upon admission and document their status in the medical record. This ensures that the client’s treatment preferences are known and respected.
B. Ensuring the client has an attorney is not a requirement of the PSDA. Clients may choose legal assistance, but it is not mandated by the act.
C. Providing end-of-life education is beneficial but not specifically required by the PSDA. The act focuses on informing clients of their rights regarding advance directives.
D. The PSDA does not require facilities to provide a list of eligible health care proxies. Instead, it ensures clients are informed of their right to appoint one.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Ensure 2 cm (0.8 in) of water is in the water seal chamber. This is correct because maintaining the correct water level in the water seal chamber is essential for proper functioning of the chest tube system, as it prevents air from entering the pleural space.
B. Check the patency of the tubing every 2 hr. This is incorrect because continuous monitoring is required, and patency should be ensured at all times, not just at set intervals. However, frequent assessments are important.
C. Keep the drainage system above the level of the client's chest. This is incorrect because the drainage system should be kept below chest level to allow gravity drainage and prevent backflow into the pleural space.
D. Empty the collection chamber every 8 hr. This is incorrect because the collection chamber should only be emptied when full, following facility protocol, to maintain an accurate record of drainage output.
Correct Answer is C
Explanation
A. The client has been in the restraints for 4 hr. This is incorrect because the duration of restraint use is determined by the client's behavior and safety, not a set time frame. Restraints should be discontinued as soon as they are no longer necessary.
B. The client can explain the reasons for their behavior. This is incorrect because insight into behavior does not necessarily indicate that the client is no longer a danger to themselves or others.
C. The client is able to calmly follow commands. This is correct because the primary indication for removing restraints is when the client demonstrates self-control and the ability to follow directions, reducing the risk of harm.
D. The client reports that the restraints are too tight. This is incorrect because a complaint of tight restraints indicates a need for reassessment and possible adjustment, but not necessarily discontinuation.
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