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.
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Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}
Explanation
Essential Interventions:
- Monitor fetal heart rate
- Administer ampicillin IV
- Place client in left lateral position
- Request a prescription for ephedrine
Contraindicated Intervention:
- Decrease the IV flow rate
Rationale:
- Monitor fetal heart rate (Essential): Epidural anesthesia can cause maternal hypotension, leading to decreased uteroplacental perfusion. Continuous fetal heart rate monitoring ensures the fetus is tolerating labor well.
- Administer ampicillin IV (Essential): The client tested positive for Group B Streptococcus (GBS) at 37 weeks, requiring prophylactic IV antibiotic administration during labor to prevent neonatal infection.
- Place client in left lateral position (Essential): This position improves venous return, enhances placental perfusion, and prevents hypotension caused by epidural anesthesia.
- Request a prescription for ephedrine (Essential): Epidural anesthesia can cause maternal hypotension, and ephedrine is a vasopressor that can help restore blood pressure if needed.
- Decrease the IV flow rate (Contraindicated): IV fluids should be maintained or increased to prevent hypotension, a common side effect of epidural anesthesia. Reducing the IV rate could exacerbate hypotension and fetal distress.
Correct Answer is A
Explanation
A. The nurse should complete an incident report and forward it to the risk manager within 24 hours as part of the facility’s protocol for reporting medication errors. This helps track errors, improve safety measures, and prevent future occurrences.
B. While a pharmacist may need to be involved in evaluating the error, there is no requirement to notify them within a specific timeframe. The priority is proper reporting and client monitoring.
C. Calling the nurse who made the error is not an appropriate action. Incident reports focus on improving systems rather than blaming individuals.
D. An incident report is not part of the medical record. It is an internal document used for quality improvement and risk management.
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