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 A
Explanation
A. The client reports pain is reduced when he is positioned on his side. This information is relevant to the client's current condition and care plan. Pain management is a critical aspect of nursing care, and informing the oncoming nurse about the client’s preferred position for pain relief ensures continuity of care and appropriate interventions.
B. The client's partner visited earlier today for 2 hours. While social interactions are important for the client’s well-being, this information is not essential for a shift report unless it directly affects the client's condition or care needs.
C. The client's mother died 4 years ago from breast cancer. While family history can be relevant for long-term medical planning, it is not pertinent to the immediate shift report, which should focus on the client's current status and care needs.
D. The client received the prescribed antibiotic every 8 hours. While medication administration is important, the oncoming nurse can verify this information in the medication administration record (MAR). Shift reports typically focus on changes in condition, ongoing concerns, and necessary interventions rather than routine medication schedules.
Correct Answer is A
Explanation
A. Encourage the client to use the overbed trapeze. Using an overbed trapeze helps the client build upper body strength, which is essential for mobility and independence following an amputation. Strengthening the arms and shoulders facilitates bed mobility, transfers, and eventual prosthetic use.
B. Keep a loose, absorbent dressing over the client's surgical site. The surgical site should be covered with a secure, sterile dressing to promote healing and prevent infection. Loose dressings can shift, increasing the risk of contamination and delayed wound healing.
C. Maintain abduction of the client's residual limb with a pillow. Prolonged abduction is not recommended, as it can lead to hip contractures. The limb should be kept in a neutral or slightly extended position to maintain proper alignment and prevent muscle shortening that could interfere with prosthetic use.
D. Caution the client to avoid a prone position while in bed. Prone positioning is actually encouraged intermittently to help stretch the hip flexors and prevent contractures. Avoiding this position may increase the risk of hip flexion contractures, making prosthetic fitting and ambulation more difficult.
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