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 A
Explanation
Choice A Reason: This is the best action because it helps the client meet their nutritional needs and prevents further weight loss. The nurse should delegate tasks that are within the scope of practice of the UAP, such as feeding assistance.
Choice B Reason: This is not an appropriate action because it requires a nursing assessment and intervention. The nurse should determine if the client is at risk for aspiration and consult with a speech therapist or dietitian before modifying the client's diet.
Choice C Reason: This is not a relevant action because it does not address the nursing problem of altered nutrition. The nurse should monitor the client's respiratory status and oxygenation, but this is not a task that can be delegated to the UAP.
Choice D Reason: This is not a sufficient action because it does not ensure that the client will consume enough food. The nurse should educate the client on the importance of high-protein foods, but this is not a task that can be delegated to the UAP.
Correct Answer is D
Explanation
Choice A reason: Confronting the nurse manager as a group may not be effective or appropriate, as it may create more conflict and resentment. The charge nurse should follow the chain of command and escalate the issue to a higher authority if the nurse manager fails to act.
Choice B reason: Attending procedures performed by the surgeon and demanding halting of the procedure if the client becomes distressed may be seen as insubordination and interference by the surgeon, who may have legal authority to perform the procedure. It may also jeopardize the client's safety and outcome.
Choice C reason: Documenting client reactions to invasive procedures performed by the physician in their medical record is important, but not sufficient. It does not address the root cause of the problem, which is the surgeon's lack of empathy and respect for clients' pain and dignity.
Choice D reason: Reporting the physician's lack of concern for clients' pain during invasive procedures to the Director of Nursing is the most important action for the charge nurse to take, as it may lead to an investigation and corrective measures. The Director of Nursing has more power and responsibility than the nurse manager to deal with such issues and protect clients' rights and welfare.
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