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 {"dropdown-group-1":"B","dropdown-group-2":"A"}
Explanation
The client's vital signs indicate worsening hypotension (BP decreased from 90/50 mmHg to 76/45 mmHg) and tachycardia (HR increased from 118 to 121 bpm), suggesting hypovolemia, possibly due to gastrointestinal (GI) bleeding from a suspected peptic ulcer (positive H. pylori test and hemoccult-positive stool). First Action – Obtain IV Access: The client is at risk for hypovolemic shock, so establishing IV access is the priority to administer fluids or blood products if needed. Second Action – Place the client in a supine position with feet elevated:This helps improve perfusion to vital organs by increasing venous return and cardiac output.
Rationale for Incorrect Options:
Rechecking oxygen saturation is unnecessary at this moment because SpO₂ is already stable at 98%.
Calling the surgical team STAT is premature; stabilization of the client’s circulation should occur first before proceeding with the endoscopy.
Correct Answer is A
Explanation
A. Place the client in a sitting position. A belt restraint should be applied while the client is in a sitting or supine position to minimize the risk of injury and ensure comfort. Proper positioning helps maintain respiratory function and circulation, reducing complications associated with prolonged immobility.
B. Ensure the restraint is placed across the client's chest. A belt restraint should be secured around the waist, not the chest, to prevent respiratory restriction. Placing it across the chest can impair breathing and increase the risk of asphyxiation, especially if the client struggles or shifts position.
C. Tie the restraint to the railing of the client's bed. Restraints should always be secured to the bed frame, never to the side rails, to prevent injury. Attaching restraints to side rails can cause excessive restriction or accidental tightening if the rails are adjusted, leading to discomfort or harm.
D. Apply the restraint under the client's clothes. Restraints should be placed over the client's clothing or gown to prevent skin irritation and pressure injuries. Applying a restraint directly against the skin increases the risk of friction, breakdown, and potential pressure ulcers over time.
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