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:Notifying the prescriber is essential, but it is secondary to obtaining objective data. The nurse must first secure timely laboratory results to report concrete values. Immediate notification without current coagulation data delays informed decision-making about reversal, dosing changes, or additional interventions.
Choice B Reason: Monitoring for signs of bleeding is important but not the priority action for the nurse because it does not address the cause of the problem or prevent further harm. The nurse should monitor the client's vital signs, hemoglobin, hematocrit, and urine output, as well as check for any signs of bleeding, such as bruising, petechiae,
hematuria, hematemesis, melena, or epistaxis.
Choice C Reason: Completing an adverse occurrence report is important but not the priority action for the nurse because it does not provide immediate intervention or treatment for the client. The nurse should complete an
adverse occurrence report after notifying the healthcare provider and implementing appropriate actions. The report should include the details of the error, such as the time, dose, route, and name of the medications involved, as well as the client's response and outcome.
Choice D Reason:Rapidly measuring PT/INR and aPTT provides objective evidence of anticoagulation level after dual therapy. These results directly influence urgent clinical decisions, such as holding anticoagulants, administering reversal agents, or preparing for interventions to control bleeding, making this the highest‑priority action.
Correct Answer is A
Explanation
Choice A reason: This client may have an infection or sepsis, which are life-threatening complications of surgery. The nurse should assess the client's vital signs, wound appearance, and laboratory results, and notify the physician immediately.
Choice B reason: This client has a chest tube to drain the pleural fluid and re-expand the lung. The amount of drainage is within normal limits and does not indicate an emergency. The nurse should monitor the client's respiratory status, oxygen saturation, and chest tube function.
Choice C reason: This client has a gunshot wound that may have caused tissue damage and bleeding. The dressing with 2 cm-sized dark red drainage may indicate fresh bleeding, but it is not excessive. The nurse should check the dressing for signs of infection, change it as ordered, and report any changes to the physician.
Choice D reason: This client has a Jackson-Pratt drain to collect the fluid from the surgical site after a mastectomy. The amount of serosanguineous fluid is expected and does not indicate a problem. The nurse should empty and measure the drain output, record it, and report any abnormalities to the physician.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today