A nurse is caring for a client who is receiving oxygen via nasal cannula at 4 L/min. Which of the following actions should the nurse take?

The nurse should determine if the client has prepared their advance directives, which are legal documents that specify the client’s wishes regarding medical care in case they become incapacitated. Advance directives can include a living will, a durable power of attorney for health care, or a do-not-resuscitate order. The nurse should respect the client’s autonomy and right to self-determination by asking about their advance directives and ensuring that they are documented and followed.

Choice A is wrong because the nurse should not delay the admission while the client fills out the facility’s advance directives form.

The client has the right to refuse or accept any treatment, including filling out an advance directives form.

The nurse should inform the client about the benefits of having advance directives, but should not coerce or pressure them to complete one.

Choice B is wrong because the nurse should not confirm with the client’s family that the consent form has been signed.

The consent form is a legal document that indicates that the client has given informed consent for the surgery, which means that they have received adequate information about the procedure, its risks and benefits, and alternative options.

The consent form should be signed by the client, unless they are a minor, mentally incompetent, or unable to communicate.

The nurse should verify that the consent form has been signed by the client or their legal representative before the surgery.

Choice C is wrong because the nurse should not explain to the client that signing the facility’s consent form means they cannot refuse care.

Signing the consent form does not waive the client’s right to withdraw consent at any time before or during the surgery.

The nurse should inform the client that they can change their mind and refuse care at any point, and that their decision will be respected and honored.

The nurse should explain that the injection is administered in order to prevent vitamin K deficiency bleeding (VKDB) in the newborn. Vitamin K is needed for blood clotting, but newborn babies have very low levels of vitamin K in their bodies at birth because only small amounts of the vitamin pass through the placenta and breast milk. VKDB can cause life-threatening bleeding in various parts of the body, such as the brain, intestines, or skin. VKDB can be classified into early-onset, classic, or late- onset depending on the time of presentation after birth. The most effective way to prevent VKDB is to give a single intramuscular dose of 0.5 to 1 mg of vitamin K to all newborn infants within 6 hours of birth.

Choice A is wrong because sepsis is not caused by vitamin K deficiency, but by bacterial infection.

Choice B is wrong because tachypnea is not caused by vitamin K deficiency, but by respiratory distress or other conditions.

Choice D is wrong because jaundice is not caused by vitamin K deficiency, but by high levels of bilirubin in the blood.