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.

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

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

Explanation

Correct choices are;

A.I should have taken an extra dose of fluticasone-salmeterol -No Understanding
Explanation: Fluticasone/salmeterol is a long-acting inhaler used for maintenance therapy in asthma. It is not meant to be used as a rescue medication for acute symptoms or exacerbations. Therefore, taking an extra dose in response to symptoms would not be appropriate.

B. I should have taken some allergy medications before going on the hike -Understanding
Explanation: Allergy medications, such as antihistamines or nasal sprays, can help reduce allergic triggers that can exacerbate asthma symptoms. Taking these medications before exposure to known triggers (like allergens during a hike) can help prevent an asthma exacerbation.

C. I have been very stressed out lately and should work on stress management -Understanding
Explanation: Stress is a known trigger for asthma exacerbations. Managing stress through techniques such as relaxation exercises, mindfulness, or therapy can help reduce the likelihood of triggering asthma symptoms.

D. I should have eaten a snack halfway through the hike - No Understanding
Explanation: While maintaining good nutrition and hydration is important for overall health, eating a snack would not necessarily prevent an asthma exacerbation unless the snack contained medications or substances that specifically manage asthma symptoms.

E. My friend smoked cigarettes during the hike - Understanding
Explanation: Secondhand smoke is a common trigger for asthma exacerbations. Being exposed to cigarette smoke can irritate the airways and worsen asthma symptoms.

A. Replace fluids IV based on intake and output. B. Record the amount of daily wound drainage. C. Turn every 2 hours around the clock from side-to-side. D. Assess skin condition and turgor for breakdown.

Correct Answer is A

Explanation

Rationale

A. Monitoring intake and output closely is essential to assess fluid balance and ensure adequate hydration. Replacing fluids intravenously based on this assessment helps maintain hemodynamic stability and prevent dehydration, electrolyte imbalances, and hypovolemia.

B. After surgery for fistula repair, it is important to monitor wound drainage to assess for complications such as infection or delayed healing. Excessive drainage may indicate issues with wound healing or ongoing inflammation, requiring timely intervention.

C. Turning the client every 2 hours helps prevent complications such as pressure ulcers and respiratory complications. It promotes circulation, prevents skin breakdown, and aids in lung expansion. However, while important, this intervention is more focused on preventing physical complications rather than directly addressing the client's immediate medical needs post-surgery.

D. Clients with inflammatory bowel disease, especially those undergoing surgery and critically ill, are at increased risk for skin breakdown due to factors such as decreased mobility, medication effects, and overall health status. Regular skin assessments help detect early signs of breakdown and allow for prompt intervention to prevent pressure ulcers or skin complications.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits The nurse begins client education and asks the client what potential asthma triggers may have been involved in her recent exacerbation. For each statement click to specify if the client has an understanding or no understanding of asthma triggers. Each row must have one option selected.

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

Explanation

A client with a history of inflammatory bowel disease develops severe ulcerative colitis and is admitted to the intensive care unit after surgery for a fistula repair. Which intervention is most important for the nurse to include in the plan of care?

Correct Answer is A

Explanation

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?

Exhibits The nurse is reviewing the client's chart. For each finding, click to indicate whether 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.

When conducting diet teaching for a client who was diagnosed with hypertension, which food(s) should the nurse encourage the client to eat? Select all that apply.

Exhibits The nurse discusses the keep to balance energy intake and output to maintain weight Click to indicate whether the following actions would be effective or ineffective for this client to achieve energy balance. Each row must have one option selected.

The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for disease and symptom management. Which response by the client indicates understanding?

The nurse is preparing for discharge a client with a history of celiac disease who now has developed multiple sclerosis. Which instruction is most important for the nurse to include in the discharge teaching plan?