An older woman with end-stage heart disease is hospitalized for severe heart failure. She is alert and requests that no heroic measures be implemented if her breathing stops.
What actions should the nurse take first?

Obtain a do not resuscitate prescription.

Set up a family conference to discuss the client's wishes.

Discuss with the client her meaning of heroic measures.

Consult the palliative care team about the client's care.

Answer and Explanation

The Correct Answer is C

The nurse should first discuss with the client her meaning of heroic measures.

This will help the nurse to understand the client’s wishes and preferences for her care.

Choice A is incorrect because obtaining a do not resuscitate prescription should be done after discussing the client’s wishes and preferences.

Choice B is incorrect because setting up a family conference to discuss the client’s wishes should be done after discussing the client’s wishes and preferences with her.

Choice D is incorrect because consulting the palliative care team about the client’s care should be done after discussing the client’s wishes and preferences with her.

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Free Nursing Study Resources

Correct Answer is ["A","C","D","E"]

Explanation

A. Solid stool with red streaks may indicate lower gastrointestinal bleeding and requires further evaluation.
B. Formed but soft stool is a normal finding and does not require follow-up.
C. Brown liquid stool may suggest diarrhea or malabsorption issues, warranting further assessment.
D. A tarry appearance can indicate upper gastrointestinal bleeding and requires prompt follow-up.
E. Multiple hard pellets may indicate constipation or dehydration and should be addressed.

A. Have the client demonstrate prescribed wound care. B. Provide written instructions in the client's native language. C. After each instruction, ask the client if he/she understands. D. Have an interpreter repeat the wound care instructions.

Correct Answer is A

Explanation

The best way to evaluate the client’s understanding of self-care at home is to have the client demonstrate prescribed wound care.

This allows the nurse to directly observe the client’s ability to perform the necessary tasks and provide feedback and clarification as needed.

Choice B, providing written instructions in the client’s native language, may be helpful but does not allow the nurse to directly evaluate the client’s understanding.

Choice C, asking the client if he/she understands after each instruction, may not be effective if the client is not comfortable expressing confusion or misunderstanding.

Choice D, having an interpreter repeat the wound care instructions, may be helpful but still does not allow for direct observation of the client’s ability to perform the necessary tasks.

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An older woman with end-stage heart disease is hospitalized for severe heart failure. She is alert and requests that no heroic measures be implemented if her breathing stops. What actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which descriptions of stool warrant additional follow-up by the nurse? (Select all that apply.).

Correct Answer is ["A","C","D","E"]

Explanation

A client who had emergency gallbladder surgery yesterday is getting ready to be discharged. The nurse knows that the client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client's understanding of self-care at home?

Correct Answer is A

Explanation

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An older woman with end-stage heart disease is hospitalized for severe heart failure. She is alert and requests that no heroic measures be implemented if her breathing stops.
What actions should the nurse take first?