The practical nurse (PN) should collect the following information during the admission assessment of a terminally ill client to an acute care facility:
Health care proxy documentation.
Name of funeral home to contact.
Client's wishes regarding organ donation.
Contact information for the client's next of kin.
Contact information for the client's next of kin.
The Correct Answer is A
This is the information that the PN should collect during the admission assessment of a terminally ill client to an acute care facility. Health care proxy documentation is a legal document that appoints a person to make health care decisions for the client when they are unable to do so themselves. It is important to have this information in case the client's condition deteriorates and they need end-of-life care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
While caring for a client with Guillain-Barre syndrome, the practical nurse (PN) should report the finding of irregular heart rate to the charge nurse. Guillain-Barre syndrome is a neurological disorder that can affect multiple body systems, including the autonomic nervous system.
Autonomic dysfunction can lead to various cardiovascular abnormalities, such as changes in heart rate and rhythm.
However, irregular heart rate can indicate potential cardiac involvement or autonomic instability, which requires prompt evaluation and intervention. Therefore, the PN should report the finding of an irregular heart rate to the charge nurse for further assessment and appropriate management.
Incorrect:
A, B- Full facial flushing and profuse diaphoresis are common symptoms that can occur in Guillain-Barre syndrome due to autonomic dysfunction. While these findings should be noted and monitored, they may not require immediate reporting unless they are severe or accompanied by other concerning symptoms.
C- Lower leg weakness is a characteristic symptom of Guillain-Barre syndrome and is expected in this condition. The PN should document and monitor the extent and progression of weakness but does not necessarily need to report it unless there are significant changes or complications.
Correct Answer is C
Explanation
The client finding that necessitates immediate attention by the practical nurse (PN) is a client who is having bright red drainage from the rectum following a colonoscopy with polyp removal. Bright red rectal bleeding can indicate active bleeding and immediate intervention is required to assess the severity of the bleeding, control the bleeding if possible, and prevent further complications.
A. The older client with a blood pressure of 100/70 after receiving meperidine for pain may require further assessment, but it does not indicate an immediate life-threatening condition.
B. Pink urine draining from the indwelling urinary catheter following a transurethral prostatectomy may be expected due to the surgical procedure, but it should still be monitored.
D. Brown-green bile draining from a T-tube after cholecystectomy for cholelithiasis is also an expected finding.
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