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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

When caring for a client with paranoid schizophrenia who has delusions or beliefs that are not based in reality, it is important to respond in a therapeutic and empathetic manner. Acknowledging the client's fear and validating their experience can help establish trust and promote open communication.

The response "This must be very frightening for you. Let's talk more about it" demonstrates empathy and a willingness to engage in further discussion, allowing the client to express their concerns and facilitating a therapeutic relationship.

A. Nursing care plan B. Incident report C. Provider's progress notes D. Controlled substance inventory record

Correct Answer is B

Explanation

An incident report is formal documentation used to report any unexpected or adverse events that occur during the course of patient care. It provides a record of the incident and helps identify areas for improvement in patient safety and quality of care. The incident report should include details about the error, the potential impact on the client, actions taken to address the error, and any necessary follow-up.

A nursing care plan is a document that outlines the client's nursing diagnoses, goals, interventions, and evaluations. It is not the appropriate place to document a medication error or incident.

The provider's progress notes are documentation made by the healthcare provider, typically documenting their assessments, diagnoses, treatment plans, and progress of the client. A medication error made by the nurse should not be documented in the provider's progress notes.

The controlled substance inventory record is a record used to track the dispensing and administration of controlled substances. While it is important to maintain accurate records of controlled substances, documenting a medication error in this record is not the appropriate place as it is primarily used for inventory management purposes

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has paranoid schizophrenia and believes that they are being followed by FBI agents who are pretending to be psychiatric staff. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

A nurse is caring for a client who has a prescription for acetaminophen 300 mg with codeine 30 mg, 1 tablet every 3 to 4 hr PRN for pain. The nurse inadvertently administers 2 tablets to the client. In which of the following locations should the nurse document this client care incident?

Correct Answer is B

Explanation

A nurse is assisting with the development of an education program for a group of older adults. Which of the following actions should the nurse take first?

A nurse is caring for a client who has a prescription for acetaminophen 300 mg with codeine 30 mg, 1 tablet every 3 to 4 hours PRN for pain. The nurse inadvertently administers 2 tablets to the client. In which of the following locations should the nurse document this alert care incident?

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