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 C

Explanation

A. An increase in calf size can be a sign of deep-vein thrombosis (DVT), but it is not specific to
DVT and can occur with other conditions such as edema.
B. Capillary refill of 2 seconds is within the expected range and is not indicative of DVT.
C. A palpable cord-like vein is a classic sign of DVT and should be further assessed and reported for appropriate intervention.
D. An extremity feeling cool to the touch can be a sign of impaired circulation but is not specific to DVT and can occur with other vascular conditions.

A. Administer bupropion 1 hr before meals. B. Allow the client access to food throughout the day. C. Weigh the client once weekly. D. Observe the client for 1 hr after meals.

Correct Answer is D

Explanation

A. Incorrect. Bupropion is not typically used as a first-line treatment for bulimia nervosa. Additionally, administering it before meals is not a standard practice for managing bulimia nervosa.
B. Incorrect. Allowing the client unrestricted access to food throughout the day may exacerbate binge-eating behaviors associated with bulimia nervosa. Structured meal plans are typically recommended instead.
C. Incorrect. While monitoring weight is important in the management of bulimia nervosa, weighing the client once weekly may not provide adequate monitoring, as fluctuations in weight can occur more frequently.
D. Correct. Observing the client for a period after meals helps to prevent purging behaviors, such as self-induced vomiting or misuse of laxatives, which are common in bulimia nervosa. This intervention allows for immediate intervention if purging behaviors are observed and can help ensure the client's safety.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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