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 C
Explanation
The client who had a radical mastectomy 36 hours ago and has a surgical drain is the most stable among the given options and is further along in the recovery process. This client may be ready for discharge with appropriate follow-up care instructions, and their bed can be utilized for the incoming clients who were injured in a tornado.
The client who had a cerebrovascular accident 8 hours ago and received thrombolytic therapy requires close monitoring and assessment for complications, such as bleeding or changes in neurological status.
The client with cervical cancer and an internal radioactive implant requires specific precautions and monitoring to ensure radiation safety and to manage any potential side effects or complications.
The client who had a lobectomy and has a chest tube drainage system needs continued monitoring of respiratory status and drainage, as well as close observation for any signs of complications or worsening condition.
Correct Answer is D
Explanation
A.Using hydrogen peroxide for wound cleaning is not recommended as it can cause tissue damage and delay healing.
B.Burn dressings should typically be changed more frequently, often at least once per day, depending on the type and severity of the burn and the type of dressing used.Delaying dressing changes could increase the risk of infection.
C.In wound care, the nurse should cleanse the least contaminated wounds first to prevent spreading microorganisms from more contaminated areas to cleaner areas. This reduces the risk of cross-contamination and infection. For burns, starting with the cleanest areas ensures a safer wound management process.
D.Applying dressings with sterile gloves is essential to maintain a sterile environment and reduce the risk of infection, especially in clients with burns who are at high risk for infection due to compromised skin integrity.
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