A nurse is assisting with the care of a client.
Select the 4 responsibilities the nurse has in relation to the client's advance directives.
Communicate advance directives status via the medical record and shift report.
Provide the client with written information about advance directives.
Inform the client that an advance directive discontinues further care.
Instruct the client that an advance directive is a legal document and must be honored by care providers.
Document that the provider discussed do-not-resuscitate status with the client.
Initiate a power of attorney for health care document.
Correct Answer : A,B,D,E
A. Communicate advance directives status via the medical record and shift report. The nurse is responsible for ensuring that all members of the healthcare team are aware of the client’s advance directives. Documenting this information in the medical record and shift report helps guide care in accordance with the client’s wishes.
B. Provide the client with written information about advance directives. Clients have the right to receive information about advance directives, including living wills and do-not-resuscitate (DNR) orders. The nurse should provide educational materials to help the client make informed decisions.
C. Inform the client that an advance directive discontinues further care. An advance directive does not automatically discontinue all medical care. It provides instructions regarding specific interventions the client wishes to accept or decline, such as resuscitation, mechanical ventilation, or artificial nutrition. The nurse should clarify this to avoid misconceptions.
D. Instruct the client that an advance directive is a legal document and must be honored by care providers. Advance directives are legally binding documents that must be followed by healthcare providers. The nurse should reinforce that the client’s wishes, as stated in the directive, will be respected.
E. Document that the provider discussed do-not-resuscitate status with the client. Proper documentation is essential to ensure the client's preferences regarding resuscitation and end-of-life care are acknowledged and followed. The nurse should record discussions regarding advance directives in the medical record.
F. Initiate a power of attorney for health care document. The nurse does not have the authority to initiate a power of attorney for health care. The client must complete this legal document independently or with legal assistance, and it typically requires notarization or witness signatures. The nurse can provide information about it but cannot create or execute it on the client’s behalf.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "Occasional small clots in the urine." Small clots in the urine can be expected in the first 24 to 48 hours following a vaginal hysterectomy due to minor bleeding from surgical manipulation. However, large or persistent clots should be reported as they may indicate active bleeding.
B. "Frequent urge to urinate." A frequent urge to urinate is common after surgery due to bladder irritation, inflammation, or the effects of anesthesia. However, if accompanied by pain, burning, or difficulty urinating, it could indicate a urinary tract infection or urinary retention requiring further evaluation.
C. "Dark red urine." Dark red urine suggests active bleeding, which is not an expected postoperative finding and requires immediate evaluation. This may indicate excessive surgical site bleeding or trauma to the urinary tract, necessitating prompt intervention by the provider.
D. "Urine output of 300 mL over 8 hr." While this is lower than the expected urine output (at least 30 mL/hr or 240 mL in 8 hours), it is not critically low. The nurse should encourage fluid intake and monitor for signs of dehydration or urinary retention before escalating the concern to the provider.
Correct Answer is D
Explanation
A. "I can have two glasses of wine with dinner." While moderate alcohol consumption may be acceptable, guidelines typically recommend limiting alcohol intake to one drink per day for women. Two glasses of wine may exceed this recommendation, and excessive alcohol can contribute to higher blood pressure.
B. "I will set my blood pressure goal at 130 over 84." The target blood pressure for individuals with mild hypertension is usually less than 130/80 mmHg. Setting a goal of 130/84 does not meet the recommended guidelines for managing hypertension effectively.
C. "I should exercise for 15 minutes two times per week!" While any exercise is beneficial, the general recommendation for adults is to engage in at least 150 minutes of moderate-intensity aerobic activity each week, which translates to about 30 minutes on most days. Exercising only two times per week for 15 minutes is insufficient for achieving cardiovascular health and blood pressure management.
D. "I should decrease my salt intake to 2 grams per day." Decreasing salt intake to 2 grams per day indicates an understanding of dietary recommendations for managing hypertension. The American Heart Association recommends limiting sodium intake to no more than 2,300 mg per day, and further reduction to 1,500 mg may be beneficial for those with hypertension. Reducing salt can help lower blood pressure effectively.
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