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 D

Explanation

Answer: D. Blurry vision

Rationale: Blurry vision, along with yellow-green halos around lights, is a sign of digoxin toxicity that can occur when the serum level of the drug exceeds 2 ng/mL. Other signs of digoxin toxicity include nausea, vomiting, anorexia, confusion, arrhythmias, and bradycardia. Tinnitus, constipation, and joint pain are not related to digoxin toxicity.

A. "I might have short-term memory loss after the procedure." B. 17 will need to follow a full-liquid diet for 24 hours after the procedure." C. "I will have a urinary catheter in place during the procedure." D. I might have occasional seizures for several days after the procedure."

Correct Answer is A

Explanation

The correct answer is A. Electroconvulsive therapy (ECT) is a procedure that uses a mild electrical current to cause a brief seizure in the brain, which can help treat severe mentalhealth conditions. One of the possible side effects of ECT is short-term memory loss, which usually resolves within a few weeks. Therefore, if the client states that they might have short-term memory loss after the procedure, they indicate an understanding of the procedure and its risks. The other statements are incorrect or irrelevant. ECT does not require a full-liquid diet, a urinary catheter, or cause seizures after the procedure.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who is starting digoxin therapy to treat heart failure. The nurse should reinforce with the client that which of the following adverse effects is a possible indication of digoxin toxicity and should be reported to the provider?

Correct Answer is D

Explanation

A nurse in an inpatient mental health facility is reinforcing teaching with a client who signed a consent form for electroconvulsive therapy. Which of the following statements by the clientindicates an understanding of the procedure?

Correct Answer is A

Explanation

A nurse is monitoring a client who is receiving a blood transfusion. The nurse identifies that the client has urticaria and is wheezing. Which of the following types of transfusion reactions should the nurse suspect?

A home health nurse is reinforcing teaching with a client who has diabetes mellitus. Which of the following statements should the nurse make to evaluate the client's use of a glucometer?

A nurse is assessing a client who is in skeletal traction for a fractured left tibia. The nurse should identify that which of the following findings indicates altered tissue perfusion of the affected extremity?

A nurse is monitoring a client's arterial pulses. The nurse should check for a dorsalis pedis pulse in which of the following locations? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

A nurse is reinforcing teaching with a client who has primary open-angle glaucoma and a new prescription for timolol eye drops. Which of the following statements indicates an understanding of the teaching?

A nurse is assisting with the care of a preschooler who has manifestations of respiratory syncytial virus (RSV). Which of the following actions should the nurse take?

A nurse is reinforcing teaching with the support person of a client who is in the first stage of labor. Which of the following instructions should the nurse include regarding effleurage?

A nurse is reinforcing teaching with a client who has GERD and a prescription for pantoprazole. Which of the following statements indicates an understanding of the teaching?