A nurse is assisting with the care of a client.
Select the 4 responsibilities the nurse has in relation to the client's advance directives.
Initiate a power of attorney for health care document.
Provide the client with written information about advance directives.
Document that the provider discussed do-not-resuscitate status with the client.
Instruct the client that an advance directive is a legal document and must be honored by care providers.
Communicate advance directives status via the medical record and shift report.
Inform the client that an advance directive discontinues further care.
Correct Answer : B,C,D,E
- Initiate a power of attorney for health care document: Nurses do not initiate or create legal documents like a power of attorney. The client must initiate this, often with legal assistance if needed.
- Provide the client with written information about advance directives: It is the nurse’s responsibility to ensure the client receives clear, written information about advance directives, including explanations of living wills, DNR orders, and medical power of attorney documents.
- Instruct the client that an advance directive is a legal document and must be honored by care providers: Nurses reinforce that advance directives are legally binding documents. They ensure the client's wishes are respected by the healthcare team throughout their care.
- Communicate advance directives status via the medical record and shift report: Once a client’s advance directive status is known, it must be accurately documented and communicated to all healthcare providers to ensure continuity and adherence to the client’s wishes.
- Document that the provider discussed do-not-resuscitate status with the client: Nurses are responsible for documenting that the conversation regarding DNR status occurred, including who had the conversation and the client's stated wishes, even though the actual discussion is led by the provider.
- Inform the client that an advance directive discontinues further care: Advance directives do not mean that all care is discontinued. Clients can still receive comfort, palliative, or supportive treatments based on their wishes outlined in the directive.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}
Explanation
- request a prescription for an increase in statin medication: Although the client's total cholesterol is elevated at 230 mg/dL, adjusting lipid management is not the immediate priority during an acute chest pain episode. The immediate focus should be stabilizing airway, breathing, and circulation.
- prepare the client for cardiac catheterization: Cardiac catheterization may ultimately be needed to assess coronary artery blockages, but before this, the client must be stabilized with oxygen and medications to control chest pain and improve oxygenation.
- administer oxygen at 2 L/min via nasal cannula: The client’s oxygen saturation dropped to 92% on room air, which is low for someone experiencing chest pain and possible myocardial ischemia. Administering supplemental oxygen improves myocardial oxygen supply and reduces cardiac workload, addressing airway and breathing priorities.
- check a STAT cardiac troponin: The client’s initial troponin level was normal, but troponin can take several hours to rise after myocardial injury. While monitoring serial troponins is important, managing oxygenation and chest pain relief takes precedence right now.
- administer sublingual nitroglycerin: After ensuring oxygenation, sublingual nitroglycerin should be administered to relieve chest pain by dilating coronary arteries and decreasing myocardial oxygen demand. It helps reduce ischemia and may prevent further cardiac injury.
- request a prescription for a beta-blocker: Beta-blockers help control heart rate and blood pressure but are not the immediate first-line response for active chest pain and oxygen desaturation. Oxygen and nitroglycerin must be prioritized first to address the acute ischemic event.
Correct Answer is D
Explanation
A. Librium: Librium (chlordiazepoxide) is a benzodiazepine used primarily for anxiety and alcohol withdrawal management. It is not typically prescribed for pain control after surgery and would not be expected in a client using a PCA pump.
B. Disulfiram: Disulfiram is used to deter alcohol consumption by causing unpleasant effects when alcohol is ingested. It has no role in pain management and would not be associated with postoperative care or PCA use.
C. Phenobarbital: Phenobarbital is a barbiturate used to control seizures and sometimes for sedation. It is not prescribed for pain relief and would not be expected for a client recovering from a hysterectomy with a PCA pump.
D. Clonidine: Clonidine can be used as an adjunct to pain management, particularly to enhance the effects of opioids and reduce the amount needed. It can help manage withdrawal symptoms and pain, making it a medication the provider might prescribe alongside a PCA pump.
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