A client, scheduled for open-heart surgery, expresses a desire not to be resuscitated if they pass away during the procedure.
What is the nurse’s subsequent course of action?
Administer the prescribed oral and intravenous pre-operative medications.
Inform the physician after the surgical procedure is complete.
Record and have a clear conversation with the client about their wishes regarding Cardio-Pulmonary Resuscitation.
Verbally communicate the client’s wishes to the supervisor of the operating room.
The Correct Answer is C
Choice A rationale:
Administering pre-operative medications does not address the client's expressed desire regarding resuscitation. It is a necessary step in preparing the client for surgery, but it does not directly relate to their preferences for end-of-life care.
Fulfilling this task does not ensure that the client's wishes are communicated to the appropriate healthcare providers, potentially leading to unwanted resuscitative efforts if the client's condition deteriorates during surgery.
It is crucial for the nurse to prioritize the client's autonomy and right to self-determination regarding their healthcare choices.
Choice B rationale:
Informing the physician after the surgery is complete is not timely and could result in the client's wishes not being respected.
The physician needs to be aware of the client's resuscitation preferences before the procedure begins to ensure that care aligns with their wishes.
Delaying communication could lead to ethical and legal dilemmas if resuscitation is attempted against the client's expressed desires.
Choice C rationale:
This is the most appropriate action because it directly addresses the client's concerns and ensures that their wishes are documented and communicated effectively.
Having a clear conversation with the client allows for exploration of their understanding of resuscitation and any potential concerns or questions they may have.
Recording the client's wishes in their medical record provides a clear record for all healthcare providers involved in their care, promoting consistency and respect for their autonomy.
Choice D rationale:
While verbally communicating the client's wishes to the operating room supervisor is important, it is not sufficient on its own.
Written documentation in the medical record is essential to ensure that the information is accurately conveyed to all members of the healthcare team and accessible throughout the client's care journey.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Circular turns involve wrapping the bandage around the limb in a continuous circle, with each layer overlapping the previous one. While this technique is effective for securing dressings on cylindrical body parts like the arm or thigh, it's not ideal for joints like the ankle. Circular turns can constrict movement and potentially impair circulation, especially if applied too tightly. Additionally, they don't provide adequate compression for wounds that require it.
Choice B rationale:
Figure-of-eight turns create a cross-over pattern around the joint, resembling the number 8. This technique offers better flexibility and movement compared to circular turns, but it's still not the most appropriate for the ankle. The cross-over pattern can create uneven pressure points and potentially lead to discomfort or even skin irritation. Moreover, it might not provide sufficient compression for wound management.
Choice C rationale:
Spiral turns involve wrapping the bandage diagonally, ascending or descending the limb, with each layer overlapping the previous one by about half its width. This technique is considered the most suitable for bandaging joints like the ankle for several reasons:
Conforms to Joint Contours: Spiral turns naturally mold to the shape of the ankle, providing even pressure distribution and avoiding constriction points. This ensures comfort and maintains proper blood flow.
Allows for Movement: The diagonal pattern accommodates the natural flexion and extension of the ankle joint, allowing for greater mobility without compromising bandage integrity.
Provides Effective Compression: Spiral turns can be applied with varying degrees of compression to suit the needs of the wound and surrounding tissue. This can help control bleeding, reduce swelling, and promote healing.
Easy to Apply and Adjust: Spiral turns are relatively straightforward to apply and can be easily adjusted if needed, making them adaptable to different wound sizes and patient needs.
Choice D rationale:
Recurrent bandaging involves wrapping the bandage back and forth over the same area multiple times, creating a thicker layer. This technique is primarily used for stumps or areas requiring significant padding and absorption. It's not typically used for bandaging joints like the ankle, as it can create excessive bulk and potentially restrict movement.
Correct Answer is D
Explanation
Choice A rationale:
While urinary tract infections (UTIs) are a potential risk with furosemide use, they are not the most immediate or anticipated effect following initiation of the medication.
UTIs can occur due to changes in urinary flow and potential catheter use.
However, furosemide's primary action is to increase urine output, which would not directly lead to a higher risk of UTIs at the onset of treatment.
Choice B rationale:
Concentrated dark urine is typically associated with dehydration or conditions that cause the kidneys to conserve water, such as kidney disease or severe fluid loss.
Furosemide, on the other hand, is a diuretic that promotes water loss through the urine, leading to more dilute urine.
Choice C rationale:
Transient incontinence can occur with furosemide due to the rapid increase in urine production, but it is not the most predictable or anticipated effect.
Increased urine production is expected, but transient incontinence may or may not occur in all patients.
Choice D rationale:
This is the most accurate and anticipated response.
Furosemide is a loop diuretic that works by inhibiting the reabsorption of sodium and chloride in the loop of Henle in the kidneys.
This leads to a significant increase in urine output, often within a few hours of administration. The urine produced is typically dilute and light-colored, as it contains a higher concentration of water and electrolytes. This is the intended effect of furosemide, as it helps to reduce fluid overload and edema.
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