A nurse is assisting with the care of a client.

Π

Nurses' Notes 1000:

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

1200:

The 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. The client states, "I am unsure what it means to have a living will or a do not resuscitate order." The client's partner states, "I 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 lifesaving measures should they become necessary. The partner states, "How can we be sure that our decision about care will be honored?"

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

Provide the client with written information about advance directives.

Document that the provider discussed do not resuscitate status with the client. Inform the client that an advance directive discontinues further care.

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

Answer and Explanation

Correct Answer : A,C,D

A.   The nurse should provide the client with written information about advance directives to ensure that the client fully understands their options and can make informed decisions about their healthcare wishes.
B.   Not a correct option because it inaccurately states that an advance directive discontinues further care. An advance directive guides the type of care a patient wants or does not want, but it does not automatically discontinue all care.
C.   The nurse should communicate the client's advance directives status to other members of the healthcare team through documentation and shift reports. The nurse should also educate the client that an advance directive is a legal document that guides healthcare decisions and must be respected by care providers.
D.   The nurse can assist the client in initiating a power of attorney for health care document, which designates a trusted person to make healthcare decisions on behalf of the client if they become unable to make decisions for themselves.

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Correct Answer is C

Explanation

A. Incorrect. While expressing empathy is important, the nurse should also provide practical information and support.
B. Incorrect. Delaying the discussion may leave the client feeling unheard and anxious about their upcoming chemotherapy.
C. Correct. This response acknowledges the client's concerns and provides a proactive solution to address the potential issue of hair loss. Offering information about head covering options demonstrates the nurse's support and willingness to help the client manage the physical and emotional impact of chemotherapy.
D. Incorrect. Dismissing the client's concern may contribute to their anxiety and apprehension about the chemotherapy process. It's important to address all aspects of the client's experience, including potential side effects like hair loss.

A. Waste containers are lined with single bags. B. Dampened cloths are used for dusting the area. C. Uncapped sharps are put in a puncture-resistant container. D. Soiled linens are placed on the floor.

Correct Answer is D

Explanation

A. Lining waste containers with single bags is a proper infection control measure.
B. Using dampened cloths for dusting can help prevent the spread of airborne particles.
C. Using a puncture-resistant container for sharps is an appropriate action to prevent needlestick injuries.
D. Correct. Placing soiled linens on the floor can lead to contamination of the environment and potential transmission of infection.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is to begin chemotherapy. The client asks the nurse about managing hair loss. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

A nurse is providing care to a client who is Immunocompromised. Which of the following should the nurse identify as a possible source of infection?

Correct Answer is D

Explanation

A nurse is reinforcing teaching about car seat safety with a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching?

A nurse is assisting with a community health program for caregivers of clients who have Alzheimer's disease. Which of the following information should the nurse include?

A home health nurse is conducting a home inspection for a client who is at risk for falls. Which of the following instructions should the nurse provide for the client?

A nurse is assisting in the care of a client who presents to the emergency department. Exhibits Complete the following sentence by selecting words from the choices below to fill in each blank: To further evaluate the client, the nurse anticipates the client will need and .

A nurse is completing postmortem documentation for a client. Which of the following information should the nurse include in the documentation?

A nurse is assisting with a community health program for caregivers of clients who have Alzheimer's disease. Which of the following information should the nurse include?

A nurse in an acute care setting is assisting in collecting client information to include in a referral for a physical therapist. Which of the following information should the nurse plan to include?

A nurse begins to bathe a newly admitted client who reports that they have not had anything to eat that day. The nurse interrupts the bath and obtains a healthy meal for the client. This action by the nurse is an example of which of the following?