A nurse is caring for a client who has AIDS. The client states, “My mouth is sore when I eat.” Which of the following instructions should the nurse provide?

Choice A reason: Nurses can witness advance directives in many settings, depending on state laws, so stating they cannot is inaccurate. This response dismisses the client’s request without providing guidance, making it incorrect and unhelpful for addressing their wishes.
Choice B reason: Including the client’s desire for advance directives in the medical record ensures their wishes are documented and respected. This aligns with the Patient Self-Determination Act, facilitating care planning, making it the correct and supportive response.
Choice C reason: Stating the client’s name can be removed from advance directives is confusing, as directives are personal and revocable, not about name removal. This response is inaccurate and irrelevant to the client’s request, making it incorrect.
Choice D reason: There is no universal age requirement of 21 for advance directives; competent adults (typically 18+) can create them. This statement is incorrect and restrictive, misinforming the client about their rights, making it inappropriate.

Choice A reason: Warming blood products prevents hypothermia during transfusion but is not the priority in a trauma patient. Airway management takes precedence, as oxygenation is critical to survival. Administering blood products comes later in the trauma algorithm, after securing the airway and stabilizing breathing, making this action secondary.
Choice B reason: Establishing a patent oral airway is the first priority in trauma care, following the ABCs (Airway, Breathing, Circulation). A clear airway ensures oxygenation, critical for preventing hypoxia in a patient with multiple injuries. Without a patent airway, other interventions are ineffective, as oxygen delivery is essential for survival and organ function.
Choice C reason: Creating a sterile field for wound care is important to prevent infection but is not the first priority in a trauma patient. Airway and breathing take precedence, as immediate life-threatening issues like hypoxia or shock must be addressed before wound care, making this action lower in priority.
Choice D reason: Administering IV fluids to maintain blood pressure is part of the circulation phase in trauma care but follows airway and breathing stabilization. Without a patent airway, fluid administration cannot address hypoxia, a primary cause of mortality in trauma. This action is secondary to ensuring airway patency.