A nurse is admitting a client who requests not to be intubated or have any other life saving measures initiated. Which of the following actions should the nurse take?
Ask the client if they have a copy of their advance directive
Inform the client that their family can override their decision
Ask the client family if they're in agreement with the client's request
Inform the client that the provider must agree with this decision
The Correct Answer is A
A. An advance directive is a legal document that outlines a person's preferences for medical treatment, including end-of-life care. Asking the client if they have a copy of their advance directive is appropriate because it can provide valuable information about their wishes regarding medical interventions. It allows the nurse to review the document to ensure that the client's current wishes align with what is documented in their advance directive.
B. In most cases, a competent adult's healthcare decisions, including decisions to refuse treatment, are legally binding and cannot be overridden by family members. It is important for the nurse to educate the client about their rights and ensure that their wishes are respected. Family members may be involved in discussions and support the client's decisions, but they cannot override a competent adult's wishes regarding their medical care.
C. While it's important to involve family members in discussions about the client's wishes, especially if they are the client's designated healthcare proxy or legally authorized decision-maker, family agreement is not required for the client's decision to refuse life-saving measures. The nurse should primarily focus on the client's expressed wishes and ensure that these wishes are understood and respected.
D. The provider's agreement with the client's decision may be necessary to document and implement the plan of care accordingly, but ultimately, the decision to refuse treatment rests with the competent client. The nurse should facilitate communication between the client and the provider to ensure that the client's wishes are understood and documented appropriately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The water temperature for handwashing should be comfortable and tolerable for the hands. Hot water can be drying to the skin and may not necessarily improve the effectiveness of hand hygiene. Ideally, the water temperature should be warm, but not uncomfortably hot or cold, to encourage thorough handwashing.
B. The amount of soap used for handwashing is important for effective cleaning. Applying 4 to 5 mL (approximately a teaspoon) of liquid soap ensures adequate coverage to create lather and effectively cleanse the hands. Too little soap may not produce enough lather to clean effectively, while too much may be wasteful.
C. During hand hygiene, it's recommended to keep the hands lower than the elbows to prevent water from running from the contaminated area (hands) to the cleaner area (elbows). This helps maintain hygiene and prevents potential contamination of the cleaned hands.
D. After washing hands with soap and water, it's important to dry them thoroughly. However, rubbing hands and arms to dry is not recommended. Instead, hands should be dried using a clean towel or paper towel. Rubbing can cause friction and potential irritation to the skin.
Correct Answer is A
Explanation
A. Tachycardia refers to a rapid heart rate, typically defined as a heart rate greater than 100 beats per minute. Theophylline can stimulate the heart and central nervous system, leading to an increase in heart rate. Tachycardia is a known adverse effect of theophylline and can occur especially if the medication is taken in higher doses or if there are interactions with other medications or caffeine.
B. Constipation is not a common adverse effect of theophylline. Theophylline primarily affects the respiratory and cardiovascular systems rather than the gastrointestinal system. Therefore, constipation is unlikely to be caused by theophylline therapy.
C. Drowsiness is generally not a common adverse effect of theophylline. Instead, theophylline is more likely to cause CNS stimulation, which can lead to insomnia, restlessness, or anxiety rather than drowsiness.
D. Oliguria refers to decreased urine output, which is not typically associated with theophylline use. Theophylline primarily affects respiratory function and cardiovascular parameters. Decreased urine output can occur in certain conditions or with medications that affect kidney function, but it is not a recognized adverse effect of theophylline.
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