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 D
Explanation
A. Platelets within the normal range indicate appropriate clotting function and are not concerning in this scenario.
B. Red blood cell (RBC) count within the normal range suggests normal oxygen-carrying capacity and is not directly related to the client's symptoms.
C. Hemoglobin (Hgb) level within the normal range indicates adequate oxygen-carrying capacity and is not directly related to the client's symptoms.
D. An international normalized ratio (INR) of 5.2 is significantly elevated and indicates that the client's blood is not clotting properly. This could be a result of excessive anticoagulation from heparin therapy, which may lead to bleeding complications such as bloody stools. Therefore, the nurse should report this finding to the provider for further evaluation and possible adjustment of the anticoagulant therapy.
Correct Answer is B
Explanation
A. "You should follow the label directions based on your child's weight." While dosing according to weight is a common practice for many medications, it's essential to emphasize the importance of avoiding aspirin in children due to the risk of Reye's syndrome, a rare but serious condition associated with aspirin use in viral illnesses.
B. "You should avoid administering aspirin to your child." This response is correct because the use of aspirin in children, especially during viral infections, can increase the risk of Reye's syndrome, a severe condition that affects the brain and liver.
C. "Your child will require an antibiotic if she develops a fever." Antibiotics are not typically
indicated for fever unless the fever is caused by a bacterial infection. It's important to address the parent's question about managing fever specifically.
D. "Your child can have two baby aspirins every 4 hours." This response is incorrect and potentially harmful. Aspirin should not be given to children due to the risk of Reye's syndrome.
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