A nurse is assisting with the care of a client. Laboratory Results
1100:
Abdominal ultrasound: mass present in small intestine proximal to ileocecal valve. 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.
Provide the client with written information about advance directives
Instruct the client that an advance directive is a legal document and must be honored by care providers
Initiate a power of attorney for health care document
Communicate advance directives status via the medical record and shift report
Document that the provider discussed-do-not-resuscitate status with the client
Inform the client that an advance directive discontinues further care
Correct Answer : A,B,C,D
Provide the client with written information about advance directives: It is important for the nurse to educate the client about advance directives, their purpose, and how they can make informed decisions about their healthcare.
Instruct the client that an advance directive is a legal document and must be honored by care providers: The nurse should explain to the client that an advance directive is a legally binding document that guides healthcare decisions, and it must be respected and followed by healthcare providers.
Communicate advance directives status via the medical record and shift report: The nurse should ensure that the client's advance directives status is accurately documented in the medical record and communicated to other members of the healthcare team during shift handoffs. This helps ensure that the client's wishes are known and respected by all involved in their care.
Initiate a power of attorney for health care document: The nurse can assist the client in initiating a power of attorney for healthcare document if the client wishes to appoint someone as their healthcare proxy or agent. This document designates someone to make medical decisions on behalf of the client if they become unable to do so.
The other options listed are not appropriate or accurate in relation to the responsibilities of the nurse regarding advance directives:
Document that the provider discussed-do-not-resuscitate status with the client: While discussing do-not-resuscitate (DNR) status may be part of the advance care planning process, it is not directly related to advance directives as a whole.
Inform the client that an advance directive discontinues further care: This statement is incorrect and misleading. An advance directive does not automatically discontinue care but rather guides the provision of care according to the client's wishes.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Correct answer: A
Option A is correct.In this scenario, the social worker is likely involved in the client's care plan and needs the medical information to provide appropriate support services.Involuntary commitment: In cases of involuntary commitment, there might be a court order allowing for information sharing to ensure the client's well-being..
Option B is incorrect because sharing client information with a client's employer is generally not appropriate without the client's explicit consent. Confidentiality must be maintained, and any concerns about safety due to substance use should be discussed with the client and appropriate healthcare professionals.
Option C is incorrect.Sharing information with a nurse from another unit after a client commits suicide is generally not appropriate unless: there is a specific reason for sharing, such as identifying potential risks to other clients, the minimum amount of information necessary is shared and the sharing complies with HIPAA (Health Insurance Portability and Accountability Act) regulations.
Option D is incorrect because sharing client information with a client's partner after the client reports intimate partner abuse could potentially compromise the client's safety. It is crucial to follow specific protocols and laws related to reporting abuse while ensuring the client's confidentiality and well-being.
Correct Answer is D
Explanation
Explanation
D. Maintain the client in high-Flower’s position
Crackles in the bases of the lungs, shortness of breath, and an increased respiratory rate are signs of pulmonary congestion, which is commonly seen in heart failure. Maintaining the client in a high-Fowler's position, with the head of the bed elevated to a 45-60-degree angle, helps reduce venous return to the heart, decreases fluid accumulation in the lungs, and improves breathing comfort for the client.
The other options are not appropriate actions for the client's condition:
Instructing the client to cough every 4 hours in (option A) is not the priority action in this situation. Coughing may not effectively address the underlying cause of pulmonary congestion and may not provide immediate relief for the client.
Encouraging the client to ambulate to loosen secretions in (option B) is not the priority action in this situation. While ambulation can be beneficial for overall health, the client's symptoms of pulmonary congestion require immediate attention to improve respiratory status.
Increasing the client's intake of oral fluids in (option C) is not the priority action in this situation. While maintaining adequate hydration is important, excessive fluid intake can worsen the symptoms of heart failure and contribute to further fluid accumulation in the lungs.
Therefore, the nurse should maintain the client in high-Fowler's position (option D) to promote optimal lung function and improve breathing comfort. It is important to promptly notify the healthcare provider of the client's condition for further assessment and intervention.
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