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 C
Explanation
A. Incorrect. While family medical history might provide some context, physical assessment findings are more directly relevant to a referral for a physical therapist.
B. Incorrect. Medical health insurance claims are administrative and financial information, not typically included in a referral for a physical therapist.
C. Correct. Physical assessment findings, such as range of motion limitations, mobility issues, gait abnormalities, and areas of pain or discomfort, are essential for a physical therapist to develop an appropriate plan of care.
D. Incorrect. Medications taken prior to admission might have some relevance, but physical assessment findings are crucial for a physical therapist to understand the client's physical condition.
Correct Answer is B
Explanation
A. Incorrect. Placing the client in a supine position may impede drainage and is not recommended for a client with a chest tube.
B. Correct. Ensuring that the chest tube drainage system is kept below the level of the client's chest allows for proper drainage of fluid and prevents backflow of drainage into the client's chest.
C. Incorrect. The collection chamber should be emptied as needed to prevent overfilling, which could obstruct drainage.
D. Incorrect. Clamping the chest tube is not indicated for a client with a chest tube set to continuous suction, as it would interfere with the function of the drainage system.
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