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 role is responsible for coordinating the continuum of care for clients with complex health needs, such as head injury. The nurse case manager collaborates with the interdisciplinary team, the client, and the family to plan, implement, and evaluate the client's care from admission to discharge.
Choice B Reason: This role is responsible for providing primary and specialty care to adults, such as diagnosing and treating acute and chronic conditions, prescribing medications, and ordering tests. The adult nurse practitioner may be involved in the client's care, but not in coordinating it.
Choice C Reason: This role is responsible for managing the daily operations of the neurology unit, such as staffing, budgeting, quality improvement, and staff development. The neurology unit supervisor may oversee the client's care while on the unit, but not throughout the continuum of care.
Choice D Reason: This role is responsible for identifying and preventing potential risks and liabilities in the healthcare setting, such as errors, injuries, infections, or lawsuits. The risk management nurse may monitor the client's care for quality and safety issues, but not for coordination.
Correct Answer is A
Explanation
Choice A Reason: Influenza is transmitted primarily through respiratory droplets. Droplet precautions require healthcare workers to wear a mask (surgical mask) when in close contact with a client. The UAP is already wearing gloves and a gown, which are appropriate for contact precautions but incomplete without a face mask for droplet protection.
Choice B Reason: A fitted respirator (e.g., N95) is unnecessary unless the client is suspected or confirmed to have an airborne transmissible disease such as tuberculosis. Influenza does not require airborne precautions.
Choice C Reason: Assigning the UAP to provide care for another client and assuming full care of the client is not necessary or feasible because it would increase the workload of the nurse and reduce the quality of care for both clients. The UAP can still assist with care for clients with influenza as long as they follow proper infection control measures.
Choice D Reason: Instructing the UAP to notify the nurse of any changes in the client's respiratory status is important but not a priority action because it does not address the issue of preventing transmission of influenza. The nurse should first ensure that the UAP wears appropriate personal protective equipment before entering the client's room.
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