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 D

Explanation

The correct answer is choiced. "Soiled dressings should be placed in a biohazard trash receptacle.".

Choice A rationale:

For a client who has Clostridium difficile, hand hygiene should be performed with soap and water, not an alcohol-based rub, as alcohol does not effectively kill C. difficile spores.

Choice B rationale:

Droplet precautions typically require wearing a mask, not necessarily a gown and gloves. Gown and gloves are more commonly associated with contact precautions.

Choice C rationale:

Following a blood spill, a bleach solution with a ratio of 1 to 10 is recommended, not 1 to 20. This higher concentration ensures effective disinfection.

Choice D rationale:

Placing soiled dressings in a biohazard trash receptacle is correct. This prevents the spread of infection and ensures proper disposal of contaminated materials.

A. Check on the client every 10 min during the bath. B. Add bath oil to the water after the client gets into the tub. C. Drain the tub water before the client gets out. D. Allow the client to remain in the bath for 30 min.

Correct Answer is C

Explanation

Answer is:Drain the tub water before the client gets out.

Explanation: This is the correct answer because it reduces the risk of slipping and falling for the client, especially if they have limited mobility or balance problems. The other options are incorrect because:

Checking on the client every 10 min during the bath is not enough to ensure their safety and comfort.The nurse should check on them more frequently, such as every 5 to 10 minutes, depending on their needs and preferences.
Adding bath oil to the water after the client gets into the tub is not a good idea because it can make the water slippery and increase the risk of falling.The nurse should add bath oil to the water before the client gets into the tub, or use a non-slip mat or shower chair.
Allowing the client to remain in the bath for 30 min is too long and can cause dehydration, hypothermia, or skin irritation.The nurse should instruct the client to remain in the tub for no longer than 20 min, unless otherwise ordered by a physician.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is reinforcing teaching with a newly licensed nurse about infection control measures. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is assisting a client who requests to take a tub bath. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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