A nurse is assisting with the care of a client.

Nurses' Notes

1000

Client states, "I am tired of undergoing treatment because it doesn't seem to be working." Client states, "I hope I am just constipated." Appendectomy scar on right lower quadrant. Abdomen is soft, tender in right lower quadrant, bowel sounds present in all four quadrants.

1200

Surgeon has notified the client that surgical removal of the mass is advisable due to the client's history of metastasis and ongoing treatment failure. The client and their partner want to discuss end-of-life care. Client states, "I am unsure what it means to have a living will or a do-notresuscitate order." The client's partner states, " don't understand what power of attorney means. Both client and partner indicate that they might wish to decline further treatment as well as further fesaving measures should they become necessary. The partner states "How can we be sure that our decision about care will be honored?"

Select the 4 responsibilities the nurse has in relation to the client's advance directives.

Communicate advance directives status via the medical record and shift report.

Document that the provider discussed do-not-resuscitate status with the client

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

Inform the client that an advance directive discontinues further care.

Facilitate a power of attorney for health care document.

Answer and Explanation

Correct Answer : A,B,C,F

The nurse is responsible for educating the client and their partner about advance directives and facilitating their decision-making process. Advance directives are legal documents that allow the client to express their preferences for medical care and treatments at the end of life.

They also enable the client to appoint a health care proxy, who is a person who can make health care decisions for the client if they are unable to do so themselves.

The nurse should provide the client with written information about advance directives, document that the provider discussed do-notresuscitate status with the client, and communicate advance directives status via the medical record and shift report.

The nurse should not instruct the client that an advance directive is a legal document and must be honored by care providers, as this may imply coercion or limit the client's right to change their mind.

The nurse should also not inform the client that an advance directive discontinues further care, as this is inaccurate and may discourage the client from completing one.

The nurse should facilitate a power of attorney for health care document only if the client wishes to designate a health care proxy.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is C

Explanation

Tucking the glove cuffs under the gown sleeves can prevent contamination of clothing and skin by microorganisms that may be present on the gown or gloves.

The nurse should apply the gown after washing hands and before putting on gloves, and tie it securely at the neck and waist.

The nurse should not push up the gown sleeves, as this can expose skin and clothing to contamination.

A. Hearing loss B. Night sweats C. Brittle nails D. Yellow patches in the mouth

Correct Answer is D

Explanation

Explanation: Yellow patches in the mouth are an indication of oral candidiasis, also known as thrush, which is a fungal infection caused by Candida albicans. Oral candidiasis can cause symptoms such as pain, burning, redness, and difficulty swallowing in addition to yellow patches on the tongue, palate, cheeks, or throat. Hearing loss, night sweats, and

brittle nails are not manifestations of candida infection.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has Clostridium difficile. When applying a cover gown, which of the following techniques should the nurse use?

Correct Answer is C

Explanation

A nurse is collecting data from a client. The nurse should identify that which of the following manifestations is an indication of a candida infection?

Correct Answer is D

Explanation

A nurse is obtaining informed consent from a client who is scheduled for an invasive procedure. The client states, "I don't understand why this procedure is necessary." Which of the following actions should the nurse take?

A nurse is caring for a child who has terminal cancer. Which of the following responses by the child's school-age brother should the nurse expect?

A nurse is reviewing the plan of care for a group of clients. The nurse should identify that informed consent is required for which of the following procedures?

A nurse is caring for a client who is receiving a continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the followingactions should the nurse take first?

A nurse is caring for a client receiving mechanical ventilation via an endotracheal (ET) tube. The high-pressure alarm is beeping, and the client is experiencing respiratory distress. The nurse is unable to determine the cause of the alarm. Which of the following actions should the nurse take?

A community health nurse is working with a group of clients. The nurse practices the ethical principle of distributive justice by performing which of the following tasks?

A nurse is preparing to complete a sterile dressing change for a client's wound. Which of the following actions should the nurse take first?

A nurse working in labor and delivery is assisting in the care of a client who is at 30 weeks of gestation. Exhibits Select the 5 findings that the nurse should recommend for follow-up.