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

Since the client is prescribed home oxygen at 1 to 2 L/min, a nasal cannula is the most appropriate device for oxygen delivery in this scenario. A nasal cannula consists of two small prongs that are inserted into the client's nostrils, delivering oxygen directly into the nasal passages. It is a comfortable and commonly used device for low-flow oxygen therapy.

Petroleum jelly is not directly related to oxygen therapy and is not typically required for the use of a nasal cannula.

A reservoir bag is not typically used with a nasal cannula. It is a component of a different oxygen delivery system called a non-rebreather mask, which is used for high-flow oxygen therapy or in emergency situations.

An oxygen mask is also not typically used with a nasal cannula. It is a separate oxygen delivery device that covers the client's mouth and nose, delivering oxygen at a higher flow rate. Masks may be used in situations where higher concentrations or flows of oxygen are required, or when the client is unable to tolerate or use a nasal cannula effectively.

A. "The headaches should decrease as you get used to the medication." B. "Swallow the tablet whole to minimize your headaches." C. "You should take the medication on an empty stomach to prevent a headache." D. "You can discontinue the medication until the headache goes away."

Correct Answer is A

Explanation

A. Correct. Isosorbide dinitrate is a medication used to prevent angina. Headaches are a common side effect when starting the medication, but they often decrease over time as the body adjusts.
B. Incorrect. Swallowing the tablet whole will not necessarily minimize headaches associated with isosorbide dinitrate.
C. Incorrect. Taking the medication on an empty stomach is not typically necessary to prevent headaches.
D. Incorrect. Discontinuing the medication without consulting a healthcare provider is not recommended, as abrupt discontinuation could lead to worsening of symptoms.

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Naxlex Comprehensive Predictor Exams

A nurse is assisting with discharge planning for a client who is prescribed home oxygen at 1 to 2 L/min. The nurse should ensure that the client has which of the following supplies upon discharge?

Correct Answer is C

Explanation

A nurse is caring for a client who reports he has headaches after taking chewable isosorbide dinitrate. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

A nurse is reinforcing dietary teaching with a client who has constipation about appropriate food choices. Which of the following food selections by the client demonstrates an understanding of the teaching?

A nurse is preparing to perform a wet-to-dry dressing change for a client who has an infected abdominal wound. Which of the following techniques should the nurse use when performing this dressing change?

A nurse is caring for a client who has been admitted to the mental health unit. While reinforcing teaching about the client's prescribed medications, the nurse communicates truthfully about the adverse effects of the medications. Which of the following ethical concepts is the nurse exhibiting?

A nurse is participating in an interprofessional team meeting for a client. Which of the following information about the client should the nurse include?

A nurse is collecting data from a client about a range of motion for various joints. Which of the following images should the nurse identify as an example of a ball an socket joint?

A nurse at a long-term care facility is reviewing the plan of care for a client who has a prescription for mitten restraints. Which of the following tasks should the nurse assign to an assistive personnel?

A nurse is contributing to the plan of care for a client who has a major depressive disorder. Which of the following recommendations should the nurse include in the plan of care?

A nurse is assisting with postmortem care for a client who was a devout follower of Islam. Which of the following actions should the nurse take?