An adult woman with metastatic pancreatic cancer has requested that no heroic measures are implemented to save her life. Instructions from the healthcare provider have been received to transfer the client to a palliative care room. Which action is most important for the nurse to take first?
Ensure transfer of the client's electronic chart code.
Give a detailed report to the accepting nurse.
Take the family to the client's new room.
Give the client written information about end-of-life care.
The Correct Answer is B
Choice A Reason: Ensuring the transfer of the client's electronic chart code is not the most important action for the nurse to take first. The electronic chart code is a unique identifier that allows access to the client's health records and care plan. While this is an important task, it is not as urgent or essential as giving a detailed report to the accepting nurse, who will be responsible for providing palliative care to the client.
Choice B Reason: Giving a detailed report to the accepting nurse is the most important action for the nurse to take first. The report should include the client's diagnosis, prognosis, pain level, medication regimen, preferences, goals, and psychosocial needs. This will ensure continuity of care and facilitate a smooth transition for the client and the family.
Choice C Reason: Taking the family to the client's new room is not the most important action for the nurse to take first. The family may need emotional support and guidance during this difficult time, but they also need accurate and timely information about the client's condition and care plan. The nurse should first give a detailed report to the accepting nurse and then accompany the family to the new room.
Choice D Reason: Giving the client written information about end-of-life care is not the most important action for the nurse to take first. The client may benefit from learning more about palliative care, hospice care, advance directives, and bereavement services, but this should be done after giving a detailed report to the accepting nurse and ensuring that the client is comfortable and stable in the new room.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Demonstrating the proper use of personal protective equipment is important, but not the first action. The charge nurse should first assess the UAP's level of understanding and address any misconceptions or fears about HIV transmission.
Choice B reason: Offering to assist the UAP with the collection of the specimen may be helpful, but not the first action. The charge nurse should first educate the UAP about HIV transmission and infection control measures, and then evaluate the UAP's competence and confidence in performing the task.
Choice C reason: Providing the UAP with the infection control policy is relevant, but not the first action. The charge nurse should first explain the rationale and principles of infection control to the UAP, and then refer to the policy as a guideline and resource.
Choice D reason: Determining the UAP's knowledge about HIV transmission is the first and most appropriate action for the charge nurse to take, as it will help identify any gaps or misinformation that may cause fear or anxiety in the UAP. The charge nurse should then provide accurate and evidence-based information about HIV transmission, prevention, and treatment, and answer any questions or concerns that the UAP may have.
Correct Answer is B
Explanation
A) This action is not the best because it does not directly evaluate the PN's wound care skills in practice. A skill checklist may not reflect the current or actual abilities of the PN, especially if it is outdated or based on self-
reporting. The charge nurse should observe the PN's performance in person to ensure that she follows the proper procedures and protocols for sterile wound care.
B) This action is the best because it allows the charge nurse to verify the PN's wound care skills and provide feedback or guidance if needed. The charge nurse has a responsibility to ensure that the PN delivers safe and effective care to the clients on the unit. By watching the PN perform sterile wound care, the charge nurse can assess her competence, confidence, and compliance with standards of practice.
C) This action is not the best because it is disrespectful and discouraging to the PN. The charge nurse should not dismiss or undermine the PN's past experience, which may have contributed to her wound care skills. The charge nurse should acknowledge and appreciate the PN's expertise, but also verify her skill level through direct
observation.
D) This action is not the best because it exposes the client to potential harm and liability. The charge nurse should not delegate a task that requires assessment and evaluation to a PN without first confirming her skill level and competency. The charge nurse should also not ask the PN to perform a task while she is busy with other duties, as this may compromise the quality and safety of care.
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