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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Free Nursing Study Resources

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

Explanation

Choice A reason: Monitoring airway and tongue during a tonic-clonic seizure is critical, as muscle contractions can obstruct the airway or cause tongue biting, leading to hypoxia. Ensuring airway patency prevents respiratory compromise, a life-threatening issue, addressing the physiological priority of oxygenation during seizure-induced neuronal hyperactivity.

Choice B reason: Darkening the room by closing blinds is not a priority during a seizure. Reducing stimuli may help photosensitive epilepsy, but active seizures require airway and safety management. Uncontrolled movements from neuronal discharges pose immediate risks, making airway monitoring and injury prevention more critical than environmental adjustments.

Choice C reason: Placing pillows inside side rails protects the child from trauma during a seizure, as tonic-clonic movements from cortical hyperexcitability risk fractures or head injuries. Padding reduces impact injuries, addressing the physiological need for safety during clonic jerking, ensuring protection against environmental hazards in the seizure setting.

Choice D reason: Asking the mother to release the child prevents harm, as restraint during a seizure can cause fractures or muscle strain by resisting neuronal-driven movements. Allowing free movement in a safe environment reduces injury risk, prioritizing physical safety and preventing complications from external resistance during the seizure.

Choice E reason: Administering an anticonvulsant requires a prescription and is not immediate during an active seizure. While drugs like lorazepam treat prolonged seizures, the nurse prioritizes airway and safety. Only trained personnel with orders can administer medications, making this less urgent than ensuring airway patency and injury prevention.

A. “Your PCA pump has just been discontinued, and you need to wait at least one hour before leaving the unit.” B. “As long as you go to the smoking area in a wheelchair, it will be all right for you to go smoke.” C. “You may smoke in your room if you keep the door closed and open a window.” D. “Smoking is hazardous to your health, and since you just had surgery, it would be best for you to avoid smoking.”

Correct Answer is D

Explanation

Choice A reason: Delaying smoking for one hour is arbitrary and does not address smoking’s risks post-surgery. Nicotine causes vasoconstriction, reducing wound perfusion, and carbon monoxide impairs oxygen delivery, delaying healing. Advising against smoking mitigates these risks, promoting recovery, making this response less effective than cessation advice.

Choice B reason: Allowing smoking in a wheelchair ignores postoperative risks. Nicotine’s vasoconstriction reduces tissue oxygenation, and carbon monoxide lowers hemoglobin’s capacity, impairing healing. This increases infection or thrombosis risk. Advising against smoking addresses these physiological harms, prioritizing wound recovery over facilitating smoking, which is detrimental.

Choice C reason: Smoking in the room violates hospital safety and exposes others to secondhand smoke. Nicotine and carbon monoxide reduce tissue perfusion and oxygen delivery, delaying postoperative healing. Advising against smoking prevents these complications, ensuring better recovery, making this response unsafe and inappropriate for surgical patients.

Choice D reason: Advising against smoking is critical, as nicotine causes vasoconstriction, reducing blood flow to surgical sites, and carbon monoxide impairs oxygen delivery, delaying healing. These increase infection and thrombosis risks post-surgery. This response promotes optimal recovery, addressing physiological needs for wound healing in the critical 24-hour period.

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Naxlex Comprehensive Predictor Exams

A child is being prepared for a computed tomography (CT) scan when the child begins to have a tonic-clonic seizure. The mother is hysterical and is trying to hold the child down. What action(s) should the nurse take? (Select all that apply)

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

Explanation

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?

Correct Answer is D

Explanation

Four hours following surgical repair of a compound fracture of the right ulna, the nurse is unable to palpate the client’s right radial pulse. Which action should the nurse take first?

Five months following treatment for Herpes zoster (shingles), an older adult client tells the home health nurse of continuing to experience pain where the rash occurred. Which action should the nurse implement?

When performing postural drainage on a client with chronic obstructive pulmonary disease (COPD), which approach should the nurse use?

After administering lisinopril, an angiotensin-converting enzyme (ACE) inhibitor, it is most important for the nurse to monitor which assessment finding?

A client with a history of schizophrenia, and drug and alcohol abuse is admitted to the hospital for hepatitis. The nurse should contact the healthcare provider before implementing which prescription?

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 nurse is caring for a client with urolithiasis who reports severe flank and abdominal pain. Which action should the nurse implement?

The nurse observes an adult client perform a return demonstration of diaphragmatic breathing. The client inhales while holding the abdomen, then removes the hand to allow expansion of the abdomen during exhalation. Which action should the nurse take after observing the client’s demonstration?