An older adult male who is in his early 70's is admitted to the emergency department because of a COPD exacerbation. The client is struggling to breathe and the healthcare team is preparing for endotracheal intubation. The spouse's wife, who is 30 years younger than the client, asks the nurse to stop the procedure and provides the nurse a copy of the client's living will. Which action should the nurse take?

Alert the nursing staff of the client's do not resuscitate status.

Facilitate a family meeting with the palliative care team.

Notify the healthcare provider of the client's wishes.

Place a certified copy of the living will in the client's record.

Answer and Explanation

The Correct Answer is C

Rationale

A. A living will often includes directives regarding life-sustaining treatments, including intubation. If the living will explicitly states a preference against intubation, the nurse should ensure this information is known to the healthcare team. However, a living will does not automatically imply a DNR status unless specifically stated.

B. When a living will is presented, and decisions need to be made regarding life-sustaining treatments like intubation, it is appropriate to facilitate a family meeting. In this meeting, the healthcare team, including palliative care specialists if available, can discuss the client's wishes as outlined in the living will. The goal is to ensure everyone understands the client's preferences and to make informed decisions about the course of treatment.

C. The nurse should notify the attending healthcare provider about the existence of the client's living will and its directives regarding medical interventions such as intubation. The healthcare provider needs to be aware of the client's wishes to guide the decision-making process and ensure appropriate care is provided according to the client's preferences.

D. It is crucial to ensure that the living will, once verified and certified as authentic, is placed in the client's medical record. This document serves as a legal and ethical guide for healthcare decisions, especially during critical situations like an exacerbation requiring intubation.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is B

Explanation

Rationale

A. Aspirin is commonly used in the emergency setting for chest pain suspected to be due to acute coronary syndrome (ACS), which includes conditions like myocardial infarction (heart attack). It works by reducing blood clotting and can help alleviate symptoms in some cases. It is typically safe to administer aspirin

B. Sildenafil can interact with nitrates, such as nitroglycerin, and result in a significant drop in blood pressure. Therefore, the nurse should withhold nitroglycerin to prevent potential adverse effects.

C. Morphine is a potent opioid pain medication used in the emergency department for severe pain relief, including chest pain associated with suspected myocardial infarction. It can help reduce pain and anxiety in acute coronary syndromes. It has no significant interaction with sildenafil.

D. Heparin is an anticoagulant medication used to prevent blood clotting. It is often administered in the hospital setting for various indications, such as deep vein thrombosis, pulmonary embolism, or in some cases of acute coronary syndromes.

Correct Answer is []

Explanation

Potential condition: Opioid-induced constipation

Actions to take

Administer a stool softener: Opioids commonly cause constipation by slowing down bowel motility and increasing water absorption in the intestines. A stool softener can help by adding moisture to the stool, making it easier to pass.

Ask the client about their normal bowel routine: Understanding the client's typical bowel habits can provide insights into any deviations caused by the surgery or medication.

Parameters to monitor

Fluid intake: Monitoring the client's fluid intake is crucial as adequate hydration helps maintain bowel function and prevents constipation.

Serum potassium level: Constipation, especially if severe or prolonged, can lead to electrolyte imbalances such as hypokalemia (low potassium levels), which can have serious health implications.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client arrives to the emergency department with chest pain after taking sildenafil. Based on the client's history, which medication should the nurse withhold?

Correct Answer is B

Explanation

Patient Data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress,

Correct Answer is []

Explanation

Potential condition: Opioid-induced constipation

Actions to take

Parameters to monitor

The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having unprotected sex. Which response should the nurse provide?

The nurse is teaching dietary modifications to a client with hypertension. Which product is the best selection to include as part of the client's lunch?

A client has developed atrial fibrillation with a ventricular rate of 150 beats/minute observed via telemetry. The client's blood pressure is 80/40 mm Hg. Which finding is most important for the nurse to report to the healthcare provider?

An older adult client with dementia who is refusing to allow an unlicensed assistive personnel (UAP) to assist in bathing, is becoming increasingly agitated and stating the UAP "wants to hurt me and tie me up." Which approach should the nurse use with the client?

Which problem reported by a client taking lovastatin requires the most immediate follow-up by the nurse?

The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms?