Which information should the practical nurse (PN) collect during admission assessment of a terminally ill client to an acute care facility?

Name of funeral home to contact.

Contact information for client's next of kin.

Health care proxy documentation

Client's wishes regarding organ donation.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C. Health care proxy documentation.

Choice A rationale:

The name of the funeral home to contact is not immediately relevant during the admission assessment of a terminally ill client. This information can be collected later as part of end-of-life planning but is not critical for the initial assessment.

Choice B rationale:

While the contact information for the client’s next of kin is important for communication and support, it is not as crucial as health care proxy documentation for making immediate healthcare decisions.

Choice C rationale:

Health care proxy documentation is essential because it designates someone to make healthcare decisions on behalf of the client if they become unable to do so themselves. This ensures that the client’s healthcare preferences and decisions are respected and followed by the healthcare team.

Choice D rationale:

The client’s wishes regarding organ donation are important but are often included in the health care proxy documentation. This information is not as immediately critical as the health care proxy documentation during the admission assessment.

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Correct Answer is C

Explanation

This is the most important information for the PN to ask because it assesses the client's risk for self-harm and suicidal ideation. The client's statements indicate hopelessness, low self-esteem, and impaired functioning, which are potential warning signs of suicide. The PN should ask the client directly about any thoughts or plans of harming themselves and provide support and safety measures as needed.

A. Questioning about which rituals are most often used to reduce anxiety is not a priority and may reinforce the client's compulsive behavior.

B. Asking if the obsessions and compulsions interfere with sleep is not a priority and may not address the client's emotional distress.

D.Determining what makes the client think people are laughing is not a priority and may not be helpful for the client's perception of reality.

A. Document the appearance of the wound as inflamed. B. Report the appearance of the dressing to the charge nurse. C. Remove the drainage device and apply a pressure dressing. D. Compress the drainage device before closing the tab. E. Clamp the drainage tubing for the next four hours.

Correct Answer is ["B","D"]

Explanation

The correct answers are Choice B and D:

Choice B: Report the appearance of the dressing to the charge nurse,

Choice D: Compress the drainage device before closing the tab.

Choice A rationale:

Documenting the appearance of the wound as inflamed is not appropriate. As a practical nurse, the immediate concern is to take action and report any concerning findings to the appropriate healthcare provider rather than just documenting it.

Choice B rationale:

Reporting the appearance of the dressing to the charge nurse is essential. The charge nurse or a more experienced healthcare provider needs to be informed of any abnormal findings or signs of infection for further evaluation and appropriate intervention.

Choice C rationale:

Removing the drainage device and applying a pressure dressing is not within the scope of practice for a practical nurse. These actions require a higher level of expertise and are typically performed by a registered nurse or healthcare provider.

Choice D rationale:

Compressing the drainage device before closing the tab is a correct action. This helps to ensure that the device is functioning properly, and there are no leaks or obstructions in the drainage system.

Choice E rationale:

Clamping the drainage tubing for the next four hours is not recommended unless specifically ordered by a healthcare provider. Clamping the drainage tubing without appropriate orders may disrupt the normal drainage process and cause complications.

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Which information should the practical nurse (PN) collect during admission assessment of a terminally ill client to an acute care facility?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The practical nurse (PN) observes a client’s initial postoperative dressing, which is saturated with serosanguinous fluid, and a drainage device that appears partially compressed. Which follow-up actions should the PN implement? (Select all that apply.).

Correct Answer is ["B","D"]

Explanation

The mother of a school-aged boy tells the practical nurse (PN) that he fell out of a tree and hurt his arm and shoulder. Which assessment should the practical nurse (PN) note as the most significant indicator of possible child abuse?

The practical nurse (PN) is assigning care for a group of clients on the urology medical unit. Which client care interventions should the PN assign to the unlicensed assistive personnel (UAP)? (Select all that apply.).

An oil retention enema is prescribed for a hospitalized client. The practical nurse (PN) should administer the enema solution at which temperature?

The practical nurse (PN) palpates a client's radial pulse and notes that the pulse disappears when light pressure is applied. How should the PN document this finding?

The practical nurse (PN) reviews the history of an older adult who is newly admitted to a long-term care facility. Which factor in the resident's history should the PN consider the most likely to increase the client's risk for falls?

The practical nurse (PN) learns that a client who is receiving chemotherapy has developed stomatitis. Which information should the PN obtain from the client during a focused assessment?

When monitoring a client's abdominal incision, the practical nurse (PN) observes a large amount of sanguineous drainage on the dressing. Which client data collection should the PN complete first?