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

The correct answer is D. Anaphylactic reactions are characterized by urticaria, wheezing, hypotension, and bronchospasm. They are caused by an IgE-mediated hypersensitivity to plasma proteins in the donor blood.

A. "Exhale immediately after inhaling." B. "Take three quick breaths while depressing the canister." C. "Close your mouth around the mouthpiece." D. Tilt your head forward while inhaling.

Correct Answer is C

Explanation

The correct answer is C. "Close your mouth around the mouthpiece." The rationale for this instruction is that it ensures that the medication reaches the lungs and does not escape through the mouth or nose. Albuterol is a bronchodilator that relaxes muscles in the airways and increases airflow to the lungs. It is used to treat or prevent bronchospasm, or narrowing of the airways, in people with asthma or certain types of chronic obstructive pulmonary disease (COPD). It is also used to prevent exercise-induced bronchospasm. Albuterol is delivered through a metered dose inhaler (MDI), which is a device that releases a measured amount of medication with each puff. To use an albuterol MDI correctly, the client should follow these steps :

Shake the inhaler well before each spray.
Remove the cap and look at the mouthpiece to make sure it is clean.
Breathe out fully.
Put the mouthpiece between your lips and close your mouth around it.
Press down on the inhaler to release the medication as you start to breathe in slowly.
Breathe in slowly and deeply over 3 to 5 seconds.
Hold your breath for 10 seconds to allow the medication to reach your airways.
Breathe out slowly.
If you need another puff, wait 1 minute and repeat steps 4 to 8.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a client who is about to start using an albuterol metered- dose inhaler. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

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