A nurse is assisting with the care of a client. Select

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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Open nearby doors and windows when the fire alarm sounds: Opening doors and windows during a fire can cause the fire to spread more rapidly by feeding it with additional oxygen. Doors should be closed to contain the fire and reduce the spread of smoke.

B. Attempt to extinguish the fire before evacuating clients: Client safety is the priority in a fire situation. Evacuation should occur first, and attempts to extinguish the fire should only be made if it is safe to do so without putting clients or staff at risk.

C. Have ambulatory clients walk independently to a safe location: Ambulatory clients should be instructed to evacuate independently if they can do so safely, freeing staff to assist clients who are immobile or require more help during the evacuation.

D. Aim the spray of the fire extinguisher at the top of the fire: The proper technique is to aim at the base of the fire, not the top, to effectively extinguish the flames by removing the fire's source of fuel.

A. A client who is receiving an enteral tube feeding and has a blood glucose level of 155 mg/dL (74 to 106 mg/dL) B. A client who has a spinal cord injury and needs a dressing change C. A client who has a temperature of 38.4° C (101.1 F) and appears confused D. A client who had a hip arthroplasty and is requesting pain medication

Correct Answer is C

Explanation

A. A client who is receiving an enteral tube feeding and has a blood glucose level of 155 mg/dL (74 to 106 mg/dL): A mildly elevated blood glucose level is not immediately life-threatening and can be managed after addressing more urgent issues. This client is stable at the moment.

B. A client who has a spinal cord injury and needs a dressing change: While important for preventing infection, a scheduled dressing change is not an immediate threat to the client’s life or health and can be safely performed after more urgent concerns are addressed.

C. A client who has a temperature of 38.4° C (101.1° F) and appears confused: Fever and new-onset confusion suggest a possible infection, such as sepsis or urinary tract infection, especially in older adults. This situation indicates a potential life-threatening condition and requires immediate assessment and intervention.

D. A client who had a hip arthroplasty and is requesting pain medication: Managing pain is important, but it is not immediately life-threatening. After addressing the client with fever and confusion, attending to the client's pain needs would be appropriate.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Correct Answer is C

Explanation

Study Resources

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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.

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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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.