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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Completing an incident report is crucial whenever an error occurs in patient care. This helps to ensure that the error is properly documented, investigated, and addressed to prevent recurrence and promote patient safety.
B. Allowing the incorrect solution to finish infusing could potentially harm the patient. Once the error is identified, the infusion should be stopped immediately, and corrective action should be taken.
C. Documenting that an error occurred in the client's medical record is important, but completing an incident report is a separate step that ensures a thorough investigation and response to the error.
D. Removing the IV catheter may be necessary if the infusion needs to be stopped, but it does not address the need to document and report the error to prevent future occurrences and ensure patient safety.
Correct Answer is B
Explanation
A. Vomiting is not a common adverse effect of electroconvulsive therapy (ECT). Nausea may occur, but vomiting is less common.
B. Confusion is a common adverse effect of ECT, especially immediately following the procedure. It typically resolves within a short time after the treatment.
C. Incontinence is not typically associated with ECT. However, urinary retention may occur in some cases.
D. Tinnitus (ringing in the ears) is not a common adverse effect of ECT. However, some clients may experience temporary hearing disturbances immediately following the procedure.
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