A nurse provides care to an older hospitalized client who is newly admitted for advanced liver failure. The client states, "I've told my doctor to let me die if my heart stops beating or if I quit breathing. I do not want to be revived." To best ensure the client's request is honored, which of the following should the nurse do?
Assure the client that their end-of-life wishes are followed right away.
Check the medical record for a DNR order.
Ask the client if they have a healthcare proxy who can speak for them if needed.
Verify a signed copy of the advance directives in the medical record.
The Correct Answer is B
Choice A reason : While it is important to assure the client, the nurse must first verify that there is a formal DNR order in place to legally honor the client's wishes¹².
Choice B reason : Checking for a DNR order in the medical record is the correct action to ensure that the client's wishes regarding resuscitation are documented and will be followed by all healthcare providers¹².
Choice C reason : Asking about a healthcare proxy is important, but it is secondary to confirming that the client's wishes are documented in the medical record through a DNR order or advance directives¹².
Choice D reason : Verifying a signed copy of the advance directives is crucial, but the immediate step is to check for a DNR order, which is specifically related to the client's request not to be resuscitated¹².
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Related Questions
Correct Answer is D
Explanation
Choice A reason : Delegating the NG tube placement to a more experienced nurse does not address the client's refusal of the procedure. The nurse must respect the client's autonomy and decision-making rights.
Choice B reason : While a referral to Social Services may be appropriate in some cases, it does not directly address the immediate concern of the client's refusal of the NG tube placement.
Choice C reason : Seeking consent from the client's spouse is not appropriate as the client is competent and has the right to refuse treatment. The client's autonomy must be respected.
Choice D reason : Documenting the client's wishes and notifying the physician is the correct action. The nurse must respect the client's right to refuse treatment and communicate this decision to the physician so that alternative management can be considered.
Correct Answer is C
Explanation
Choice A reason : This statement is misleading. While heparin does need to reach a therapeutic level to be effective, it does not directly dissolve existing clots. Heparin's primary action is to prevent the formation of new clots and the extension of existing clots by inhibiting certain factors in the coagulation cascade.
Choice B reason : While a pharmacist can provide detailed information about medications, it is the nurse's responsibility to educate and inform the client about the effects of their treatment. Therefore, this response would not be appropriate.
Choice C reason : This is the most accurate response. Heparin works by inhibiting the formation of fibrin, which is essential for clot formation. It does not have the ability to dissolve existing clots but can prevent new ones from forming and existing ones from getting larger.
Choice D reason : Oral medications such as warfarin or direct oral anticoagulants (DOACs) may be used after heparin to maintain anticoagulation; however, they also do not dissolve clots. The body's natural fibrinolytic system is responsible for breaking down clots over time.
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