An elderly male patient in his early 70s is admitted to the emergency department due to a COPD exacerbation.
The patient is having difficulty breathing and the healthcare team is preparing for endotracheal intubation.
The patient’s wife, who is 30 years younger, asks the nurse to halt the procedure and presents the nurse with a copy of the patient’s living will.
What should the nurse’s next step be?

Place a certified copy of the living will in the patient’s record.

Inform the healthcare provider of the patient’s wishes.

Arrange a family meeting with the palliative care team.

Notify the nursing staff of the patient’s do not resuscitate status.

Answer and Explanation

The Correct Answer is B

Choice A rationale

While placing a certified copy of the living will in the patient’s record is important, it is not the immediate next step. The living will should be acknowledged, but the healthcare provider needs to be informed immediately.

Choice B rationale

Informing the healthcare provider of the patient’s wishes is the most appropriate next step. The healthcare provider can then make decisions based on the patient’s expressed wishes.

Choice C rationale

Arranging a family meeting with the palliative care team may be beneficial, but it is not the immediate next step. The healthcare provider needs to be informed first.

Choice D rationale

Notifying the nursing staff of the patient’s do not resuscitate status is important, but it is not the immediate next step. The healthcare provider needs to be informed first.

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"}}

Explanation

Based on the provided information, here are the interventions the nurse should perform:

Check capillary refill on bilateral upper extremities.- Indicated: This is important to assess the client’s circulation, especially given the coolness of the left arm and the fracture in the left shoulder.
Administer ondansetron 4 mg IV.- Contraindicated: There is no prescription for ondansetron and no indication of nausea or vomiting from the client.
Inspect the bandage for drainage.- Indicated: Given the client’s recent surgery and the presence of swelling and bruising, it’s important to monitor for any signs of infection or complications.

A. Take prescribed cortisone accurately. B. Use a walker when weakness occurs. C. Increase daily intake of sodium in diet. D. Avoid extreme environmental temperatures.

Correct Answer is A

Explanation

Choice A rationale

Taking prescribed cortisone accurately is crucial for managing multiple sclerosis symptoms. Cortisone is a type of steroid that can reduce inflammation and suppress the immune system, helping to manage MS symptoms.

Choice B rationale

Using a walker when weakness occurs can be beneficial for patients with multiple sclerosis as it can help them maintain mobility and independence. However, it is not the most important instruction for the nurse to include in the discharge teaching plan.

Choice C rationale

Increasing daily intake of sodium in the diet is not recommended for patients with multiple sclerosis. High sodium intake can exacerbate symptoms of multiple sclerosis and may increase the risk of relapses.

Choice D rationale

Avoiding extreme environmental temperatures can be beneficial for patients with multiple sclerosis as heat can worsen symptoms. However, it is not the most important instruction for the nurse to include in the discharge teaching plan.

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Naxlex Comprehensive Predictor Exams

Exhibits Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"}}

Explanation

A patient with a history of celiac disease has recently been diagnosed with multiple sclerosis.The nurse is preparing to discharge the patient.What is the most important instruction for the nurse to include in the discharge teaching plan?

Correct Answer is A

Explanation

What advice should a nurse give to a patient who is about to undergo a cystoscopy?

A young adult is admitted to the emergency department after consuming an unknown quantity of drugs.The patient is unresponsive, and an endotracheal tube (ETT) has been inserted.What methods should the nurse use to confirm the correct placement of the ETT? Select all that apply.

A nurse is assessing a 3-month-old patient who underwent a pyloromyotomy the previous day.Which of the following findings would indicate a need for pain medication? Select all that apply.

After a scheduled downtime, the computer documentation system fails to restart.What should be the nurse’s initial action?

On the first day at 1830, certain medical procedures were initiated for the patient.Which of the following procedures were likely to have been initiated based on the patient’s condition?

The nurse is conducting a functional assessment on an older patient who has lost five pounds (2.27 Kg) since the last visit 12 weeks ago and reports a decrease in energy and appetite.Which action should the nurse include during the assessment?

A straight catheter produced 500 mL of clear yellow urine. For each finding, indicate whether the findings suggest that the client’s condition has improved or put the client at risk for hypovolemia. Each column must have at least one selection.