A nurse is assisting with the care of a client.

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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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Correct. Placenta previa is a condition where the placenta covers part or all of the cervix.
Bright red vaginal bleeding, especially painless bleeding, is a hallmark sign of placenta previa.
B. Incorrect. Persistent uterine contractions are not a typical finding in placenta previa and could indicate preterm labor or other issues.
C. Incorrect. Increased fetal movement is not a characteristic sign of placenta previa.
D. Incorrect. A rigid abdomen is not associated with placenta previa; it could be a sign of other conditions such as placental abruption.

A. Keep the airbag on if the car seat is in the front seat. B. Position the car seat at a 90° angle. C. Put a small cushion under the newborn's head for support. D. Place the shoulder harnesses at the level of the infant's shoulders.

Correct Answer is D

Explanation

A. Incorrect. The airbag should be turned off if an infant car seat is placed in the front seat, as airbags can pose a significant risk to infants.
B. Incorrect. The car seat should be positioned at a 45° angle to prevent the infant's head from falling forward and obstructing the airway.
C. Incorrect. Placing a small cushion under the newborn's head is not recommended, as it can interfere with proper positioning and safety in the car seat.
D. Correct. The shoulder harnesses of the car seat should be positioned at the level of the infant's shoulders to ensure proper fit and safety during travel.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has placenta previa. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with new parents about car seat safety. Which of the following instructions should the nurse include?

Correct Answer is D

Explanation

A nurse is collecting data from a 4-month-old infant at a well-child visit. For which of the following findings should the nurse notify the provider?

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 reinforcing teaching with a female client who is taking phenytoin. Which of the following statements should the nurse include in the teaching?

A nurse is assisting with the care of a client following electroconvulsive therapy for the treatment of a depressive disorder. Which of the following findings should the nurse expect 15 minutes following the procedure?

A nurse overhears two assistive personnel (AP. in the nurses' station discussing a client who was recently admitted. Which of the following actions should the nurse take?

A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend?

A nurse is reinforcing teaching about newborn care with a new guardian. Which of the following statements by the guardian indicates an understanding of the teaching?

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 following actions should the nurse take first?