A nurse is admitting a client who is scheduled for an elective surgery. Which of the following actions should the nurse take to verify the status of the client's advance directives?

Ask the client whether they have advance directives.

Refer to the client's identification card for their advance directives status.

Verify the client's advance directives with their health care surrogate.

Check for a written do-not-resuscitate prescription in the client's medical record.

Answer and Explanation

The Correct Answer is A

A.   Ask the client whether they have advance directives: Directly asking the client ensures that the nurse obtains accurate and up-to-date information regarding the client's advance directives.
B.   Refer to the client's identification card for their advance directives status: While some clients may carry identification cards indicating their advance directives status, relying solely on this information may not be comprehensive or up-to-date.
C.   Verify the client's advance directives with their health care surrogate: This step may be necessary if the client is incapacitated or unable to communicate, but it should not replace direct communication with the client.
D.   Check for a written do-not-resuscitate prescription in the client's medical record: While checking the medical record is important, advance directives may include more comprehensive instructions beyond do-not-resuscitate orders, so direct communication with the client is essential.

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Correct Answer is D

Explanation

A. Hypernatremia: Hypernatremia (elevated sodium levels) is not typically associated with the emergent phase of burn injuries.
B. Hypercalcemia: Hypercalcemia (elevated calcium levels) is not typically associated with the emergent phase of burn injuries.
C. Hypermagnesemia: Hypermagnesemia (elevated magnesium levels) is not typically associated with the emergent phase of burn injuries.
D. Hyperkalemia: Hyperkalemia (elevated potassium levels) is a common electrolyte imbalance seen in the emergent phase of burn injuries due to the release of potassium from damaged cells.
It can lead to cardiac dysrhythmias and other complications if not promptly addressed.

A. Encourage the client to gain 2.3 kg (5 lb) per week. B. Monitor the client for 15 min after meals. C. Weigh the client each morning after voiding. D. Reinforce teaching about healthy eating during meals.

Correct Answer is B

Explanation

A. Encourage the client to gain 2.3 kg (5 lb) per week. This is not appropriate. Weight gain should be gradual in clients with anorexia nervosa, typically around 0.5 to 1 kg (1 to 2 pounds) per week, to prevent refeeding syndrome and support psychological adjustment.

B. Monitor the client for 15 min after meals. This is the correct intervention. Clients with anorexia nervosa may engage in purging behaviors (such as vomiting or excessive exercise) after meals. Monitoring for a period of time after eating helps prevent these behaviors and ensures safety.

C. Weigh the client each morning after voiding. Weighing clients with anorexia nervosa can be distressing and should be done consistently at the same time each day (ideally, before breakfast) but does not need to be after voiding. This may not be the priority intervention compared to monitoring post-meal behavior.

D. Reinforce teaching about healthy eating during meals. While teaching about healthy eating is important, it should not be done during meals, as clients with anorexia nervosa may have difficulty focusing on this information when under stress during eating. Instead, nutrition education should be provided outside of meals.

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A nurse is admitting a client who is scheduled for an elective surgery. Which of the following actions should the nurse take to verify the status of the client's advance directives?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medical record of a client who has sustained a full-thickness burn and is in the emergent phase of the burn. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A nurse is assisting with planning care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse recommend to include in the plan of care?

Correct Answer is B

Explanation

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