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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The decision to place a loved one in long-term care is complex and should be made based on the family's needs and situation, not dictated by the nurse.
B. Suggesting the son find other family members for help is a reasonable idea, but it does not directly address his fatigue.
C. While taking care of a loved one is important, making the son feel obligated is not supportive or helpful.
D. Correct. Respite care provides temporary relief to caregivers and can help address the son's fatigue while ensuring his mother's needs are met.
Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"B"}
Explanation
When interpreting test results, particularly for an infectious disease like tuberculosis (TB), the nurse must prioritize specific infection control measures to prevent the spread of the disease.
The correct actions are:
- Wear an N95 respirator mask: This mask is essential for protecting the nurse and others from inhaling airborne pathogens that the client with TB might expel.
- Place the client in a room with negative air pressure: This type of room ensures that airborne contaminants do not escape into the hallway or other areas, thereby containing the infection and protecting others in the healthcare facility.
These measures are critical in managing the spread of TB and ensuring the safety of both healthcare workers and other patients.
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