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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
During an intravenous pyelogram (IVP), a contrast dye is injected into the client's veins, and X-ray images are taken to visualize the urinary tract. The dye used in an IVP can cause a warming or flushing sensation as it circulates through the body. The client's statement indicates an understanding of this common sensation associated with the procedure.
"I can have a meal up to 2 hours before the procedure": This statement is incorrect. Typically, for an IVP, the client is required to have an empty stomach before the procedure to ensure accurate imaging results. The client should follow the specific instructions provided by their healthcare provider regarding fasting before the procedure.
"I do not need to sign a consent form before this procedure": This statement is incorrect. Informed consent is required for most medical procedures, including an IVP. The client should sign a consent form after receiving all the necessary information about the procedure, its risks, and benefits.
"I should limit my fluid intake for 2 days after the procedure": This statement is incorrect. After an IVP, it is generally advised to increase fluid intake to help flush out the contrast dye from the body and prevent potential complications. The client should follow the specific instructions provided by their healthcare provider regarding post-procedure fluid intake.
Correct Answer is C
Explanation
Informed consent is a legal and ethical requirement for certain medical procedures. It involves providing the client with clear and comprehensive information about the procedure, including its risks, benefits, alternatives, and expected outcomes. The client must understand the information provided and voluntarily give their consent before the procedure can be performed.
Placement of a central venous catheter is an invasive procedure that carries risks and potential complications, making it necessary to obtain informed consent from the client.
Wound irrigation with an antibiotic solution is a standard nursing intervention for wound care and does not usually involve invasive procedures. Informed consent is not typically required for this procedure.
The administration of an iron injection using the Z-track technique is a standard nursing procedure. While it involves an injection, it is not typically considered an invasive procedure that would require informed consent.
Insertion of a nasogastric tube is a common procedure that involves passing a tube through the nose and into the stomach for various purposes, such as feeding, decompression, or medication administration. While it is an invasive procedure, it is often performed in emergency or critical care situations where the client's immediate well-being takes precedence. Informed consent may not be feasible or necessary in these situations, depending on the context and urgency.
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