Struggling to breathe, an older adult client with end-stage chronic obstructive pulmonary disease (COPD) is admitted through the emergency department. The client is anxious and considering mechanical ventilation when the spouse interrupts the nurse and hands the nurse a copy of the client’s living will. Which action is most important for the nurse to take?

Facilitate a family meeting with the palliative care team.

Alert the nursing staff of the client’s do not resuscitate wishes.

Place a certified copy of the living will in the client’s electronic health record (EHR).

Notify the healthcare provider of the client’s wishes.

Answer and Explanation

The Correct Answer is D

Choice A reason: Facilitating a family meeting with palliative care discusses end-of-life goals in COPD, where airway obstruction causes respiratory failure. However, notifying the provider of the living will ensures immediate alignment with the client’s wishes, especially on ventilation, addressing the urgent need to respect legal directives in a critical scenario.

Choice B reason: Alerting staff about do-not-resuscitate (DNR) wishes assumes the living will specifies DNR, which requires confirmation. The provider must review the document first, as end-stage COPD necessitates clarity on ventilation preferences to guide urgent care, making notification the priority over premature staff alerts.

Choice C reason: Placing the living will in the EHR ensures documentation but does not immediately affect care. In end-stage COPD with respiratory distress, notifying the provider ensures the client’s wishes, like avoiding intubation, are followed promptly, preventing unwanted interventions, making this more urgent than administrative tasks.

Choice D reason: Notifying the provider of the living will is critical, as it legally specifies the client’s preferences, potentially refusing ventilation in end-stage COPD, where dyspnea results from irreversible obstruction. This ensures treatment respects autonomy, guiding immediate care to align with palliative goals, preventing inappropriate interventions during a crisis.

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Correct Answer is C

Explanation

Choice A reason: Dry skin and inelastic turgor reflect dehydration in DI from antidiuretic hormone deficiency, causing water loss. This is less urgent than hypernatremia (185 mEq/L), which dehydrates brain cells, risking seizures or coma, requiring immediate fluid correction to prevent neurological damage in this critical condition.

Choice B reason: Tachycardia (110 beats/minute) compensates for hypovolemia in DI, where water loss reduces preload, triggering sympathetic activation. This is less critical than hypernatremia (185 mEq/L), which causes cerebral dehydration, necessitating urgent hypotonic fluids to prevent neurological complications, making heart rate secondary.

Choice C reason: Serum sodium of 185 mEq/L indicates severe hypernatremia in DI, where water loss concentrates sodium, dehydrating neurons and risking seizures or coma. Immediate IV hypotonic fluids (e.g., 5% dextrose) correct osmolarity, preventing life-threatening cerebral complications, addressing the urgent pathophysiological crisis in DI.

Choice D reason: Polyuria and thirst are hallmark DI symptoms from water loss but expected and less urgent than hypernatremia (185 mEq/L), which threatens neurological function via osmotic brain injury. Correcting sodium is critical to prevent seizures, making these symptoms secondary to urgent electrolyte management.

A. Administer the prescribed warfarin dose. B. Notify the healthcare provider immediately. C. Encourage increased intake of green leafy vegetables. D. Monitor for signs of bleeding every 8 hours.

Correct Answer is B

Explanation

Choice A reason: Administering warfarin with an INR of 4.8 is dangerous, as it exceeds the therapeutic range (2.0–3.0), indicating excessive anticoagulation. This risks bleeding, as warfarin inhibits vitamin K-dependent clotting factors. Notifying the provider ensures dose adjustment or reversal, preventing hemorrhage, making this action unsafe.

Choice B reason: An INR of 4.8 indicates over-anticoagulation in atrial fibrillation, increasing bleeding risk due to warfarin’s inhibition of clotting factors. Notifying the provider is critical for dose reduction or vitamin K administration, addressing the pathophysiological risk of hemorrhage, ensuring patient safety and preventing life-threatening complications.

Choice C reason: Encouraging green leafy vegetables, high in vitamin K, counteracts warfarin, lowering INR, but is inappropriate without provider guidance at INR 4.8, risking bleeding. Provider notification ensures controlled management, as unregulated dietary changes disrupt anticoagulation stability, making this action potentially harmful.

Choice D reason: Monitoring for bleeding is important but secondary to notifying the provider at INR 4.8, indicating critical over-anticoagulation. Immediate provider intervention adjusts warfarin or administers reversal agents, preventing hemorrhage. Monitoring delays urgent action needed to correct the clotting factor imbalance, making it less immediate.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which data warrants the most immediate intervention by the nurse for a client with diabetes insipidus (DI)? Reference Range: Sodium [136 to 145 mEq/L (136 to 145 mmol/L)].

Correct Answer is C

Explanation

A client with a history of atrial fibrillation is prescribed warfarin. The nurse notes the client’s INR is 4.8. Which action should the nurse take? Reference Range: INR [2.0 to 3.0 for atrial fibrillation].

Correct Answer is B

Explanation

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

When the nurse discontinues a 24-hour postoperative client’s patient-controlled analgesia (PCA) pump, the client asks to go to the hospital’s smoking area to smoke a cigarette. Which response should the nurse provide?

The nurse is initiating a 24-hour urine collection for a client with an indwelling urinary catheter. After emptying all the urine from the collection bag, which action is most important for the nurse to implement?

On the second postoperative day, a client reports increasing abdominal pain. Assessment findings include a distended abdomen with absent bowel sounds. Which intervention should the nurse anticipate implementing?

The parents of a male infant newborn have signed an informed consent for circumcision. Which priority intervention should the nurse implement upon completion of the circumcision procedure?

The nurse is developing a teaching plan for a client with peripheral arterial disease (PAD) who has a history of myocardial infarction (MI) and smokes two packs of cigarettes daily. Which instruction has the highest priority?

An older male client reports nocturia with difficulty starting his urine stream. Which additional assessment should the nurse perform to obtain further data related to this information?