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

Explanation

The descriptions that warrant additional follow-up by the nurse are choices A, D, and E.
Solid with red streaks may indicate blood in the stool1.
A tarry appearance may indicate bleeding in the upper digestive tract1.
Multiple hard pellets may indicate constipation1.

Choice B is not an answer because brown liquid stool is not necessarily a cause for concern.

Choice C is not an answer because formed but soft stool is considered normal.

A. Ask the client to describe the pain. B. Provide a numeric pain scale. C. Identify effective pain relief measures. D. Observe body language and movement.

Correct Answer is A

Explanation

To assess the quality of the client’s pain, the nurse should ask the client to describe the pain.

This will help the nurse to understand the characteristics of the pain and how it is affecting the client.

Choice B is incorrect because providing a numeric pain scale only assesses the intensity of the pain, not its quality.

Choice C is incorrect because identifying effective pain relief measures does not assess the quality of the pain.

Choice D is incorrect because observing body language and movement only provides indirect information about the quality of the pain.

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

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

Explanation

A client arrives at the emergency department (ED) with severe right upper quadrant pain. To assess the quality of the client's pain, which approach should the nurse use?

Correct Answer is A

Explanation

A client who is on complete bedrest frequently calls the nurse for the bedpan to urinate. Which action should the nurse take to evaluate the client for urinary retention?

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A client arrives at the emergency department (ED) with severe right upper quadrant pain. To assess the quality of the client's pain, which approach should the nurse use?

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An ulcerated foot peronet (FP) is to be implemented. The UAPs state they have not yet been educated on this before charging assignments. What action should the nurse take first?

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?

While changing the dressing of a client with a leg ulcer, the nurse observes a red, tender, and swollen wound at the site of the lesion. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

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?