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

A. Instructing the client to hold the drainage bag at waist height when ambulating is incorrect because the drainage bag should always be kept below the level of the bladder to prevent urine from flowing back into the bladder, which could lead to a urinary tract infection (UTI).
B. Collecting a sterile specimen from the urinary drainage bag is incorrect because urine in the drainage bag is not considered sterile. If a sterile specimen is needed, it should be obtained by cleaning the catheter's sampling port with an antiseptic solution and withdrawing urine directly from the port using a sterile syringe.
C. Securing the tubing with adhesive tape to the lower abdomen is correct because it helps prevent accidental pulling or tugging on the catheter, which could cause discomfort or dislodgement. Properly securing the tubing also helps maintain a continuous flow of urine and reduces the risk of infection.
D. Coiling the tubing on the bed above the collection bag is incorrect because it can cause urine to flow back into the bladder, increasing the risk of infection and compromising the effectiveness of the drainage system. The tubing should be kept below the level of the bladder to ensure proper drainage.

A. Baked chicken breast B. Orange juice C. Sweet potato D. Cantaloupe

Correct Answer is A

Explanation

A. Correct. Baked chicken breast is relatively low in potassium compared to the other options.
B. Incorrect. Orange juice is high in potassium.
C. Incorrect. Sweet potatoes are high in potassium.
D. Incorrect. Cantaloupe is moderately high in potassium.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an Indwelling catheter with a urinary drainage system. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a client who has an electrolyte imbalance. Which of the following foods should the nurse include as the lowest in potassium?

Correct Answer is A

Explanation

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?

A nurse is collecting data from a client during a routine prenatal visit. The client is in their second trimester of pregnancy and reports feeling dizzy, has a racing heart, and becomes pale while lying on their back. Which of the following actions should the nurse take?

A nurse is collecting data from a client during a routine prenatal visit. The client is in their second trimester of pregnancy and reports feeling dizzy, has a racing heart, and becomes pale while lying on their back. Which of the following actions should the nurse take?

A nurse is preparing to test a client's plantar Babinski reflex. Which of the following Instructions should the nurse give to prepare the client for this test?

A nurse is reinforcing teaching to a newly licensed nurse about bowel sounds. Which of the following characteristics should the nurse use to describe hyperactive bowel sounds?

A nurse is assisting in the care of a newly admitted client. Which of the following findings should the nurse report immediately to the provider? Select all that apply.

A nurse on a pediatric unit is caring for a toddler who has poor dietary intake. Which of the following actions should the nurse take first?