A nurse is assisting with the care of a client.
Laboratory Results
Abdominal ultrasound: mass present in small intestine proximal to the ileocecal valve. The size of mass is 6 cm x 7
cm (2.4 in x 2.8 in).
Select the 4 responsibilities the nurse has in relation to the client's advance directives.
Inform the client that an advance directive discontinues further care.
Initiate a power of attorney for health care documents.
Document that the provider discussed do-not-resuscitate status with the client.
Provide the client with written information about advance directives.
Communicate advance directives status via the medical record and shift report.
Instruct the client that an advance directive is a legal document and must be honored by care providers.
Correct Answer : C,D,E,F
A. Inform the client that an advance directive discontinues further care. This statement is incorrect. An advance directive does not discontinue further care but outlines the client's preferences for medical treatment if they become unable to communicate their wishes.
B. Initiate a power of attorney for health care documents. This is not the nurse's responsibility. Initiating a power of attorney for health care documents typically involves legal consultation, and the client should be referred to appropriate resources.
C. Document that the provider discussed do-not-resuscitate status with the client. This is correct. The nurse should document that the provider has discussed DNR (Do Not Resuscitate) status with the client, ensuring that the discussion and decision are clearly recorded in the medical record.
D. Provide the client with written information about advance directives. This is correct. The nurse is responsible for providing the client with written information about advance directives, ensuring the client understands their rights and options.
E. Communicate advance directives status via the medical record and shift report. This is correct. The nurse must ensure that the client's advance directive status is clearly communicated in the medical record and during shift reports to ensure continuity of care.
F. Instruct the client that an advance directive is a legal document and must be honored by care providers. This is correct. The nurse should inform the client that an advance directive is a legal document that healthcare providers are required to honor, according to the client's wishes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
When administering oral medications, the nurse should verify the medication three times with the medication administration record to ensure that the correct medication is being given to the correct client at the correct time. This is known as the "three checks" and is an important step in preventing medication errors.
Correct Answer is B
Explanation
As a nurse, the intervention that should be recommended is encouraging the client to take frequent walks during the day. This will help the client expend some energy and reduce the restlessness that could be causing the sleep disturbance at night.
The other options are not recommended because barbiturate medications can cause excessive sedation, allowing the client to nap for at least 1 hour during the day can interfere with their ability to sleep at night, and putting a lock on the client's door can be a safety risk in case of an emergency.
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