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 C
Explanation
The presence of edema and coolness around the catheter's insertion site suggests that infiltration may have occurred. Infiltration refers to the unintended leakage of fluid into the surrounding tissues instead of flowing into the vein. It can lead to tissue damage and compromised circulation. Stopping the infusion is the initial priority to prevent further infiltration and minimize potential harm to the client.
Applying a warm compress may be appropriate to promote comfort and circulation in some cases, but it should be done after stopping the infusion and assessing the severity of the infiltration.
Documenting the infiltration is necessary for accurate record-keeping and to communicate the occurrence to the healthcare team. However, it is not the first immediate action required in this situation.
Elevating the arm can help reduce swelling and promote venous return. It can be done after stopping the infusion, but it is not the first action to address the potential infiltration.
Correct Answer is A
Explanation
RSV is primarily transmitted through respiratory droplets when an infected person coughs or sneezes. To prevent the spread of RSV, it is important to implement droplet precautions. These precautions include wearing a mask and ensuring proper hand hygiene when in contact with the preschooler.
This helps minimize the risk of transmitting the virus to other individuals. Requesting an x-ray of the preschooler's neck is not indicated for RSV. RSV primarily affects the respiratory system, and an x-ray of the neck would not provide relevant information for the diagnosis or management of RSV.
Monitoring the preschooler's urine for protein is not specifically related to RSV. Proteinuria is not a typical manifestation or complication of RSV. Monitoring urine for protein is more relevant in conditions such as kidney disease or urinary tract infections.
Administering fluconazole to the preschooler is not indicated for RSV. Fluconazole is an antifungal medication used to treat fungal infections, and it would not be effective against a viral infection like RSV.
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