A murse is caring for an older adult client who has advanced dementia and needs a blood transfusion. The client previously designated her ad daughter on a durable power of attorney for health care form, and the daughter refuses the treatment. Which of the following actions should the nurse take?

Respect the daughter's decision to refuse the transfusion.

Encourage the daughter to let her mother have the transfusion.

Discuss taking guardianship of the client with the facility administration.

Ask the provider to give consent for the transfusion

Answer and Explanation

The Correct Answer is A

A. Respect the daughter's decision to refuse the transfusion. Since the daughter has been designated as the durable power of attorney for health care, she has the legal authority to make medical decisions on behalf of her mother. The nurse should respect her decision, even if it involves refusing treatment.

B. Encourage the daughter to let her mother have the transfusion. While the nurse can provide information and support, they should not pressure or coerce the daughter into making a different decision.

C. Discuss taking guardianship of the client with the facility administration.This is unnecessary as the daughter already has the legal authority to make decisions through the durable power of attorney.

D. Ask the provider to give consent for the transfusion.The provider cannot override the decision made by the designated durable power of attorney unless there is evidence that the daughter is not acting in the client's best interest.

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Correct Answer is D

Explanation

A. Medication administration record:

The medication administration record (MAR) primarily contains information related to medications, dosages, and administration times. While it provides important details about medications, it may not offer a comprehensive overview of the client's overall care.

B. Standardized care plan:

A standardized care plan typically outlines general care guidelines and interventions for specific conditions. It may provide a structured approach to care but might lack the individualized details needed for a specific client.

C. 180 record:

The term "180 record" does not commonly refer to a standard nursing documentation form. It might be a local or facility-specific term. Without additional information, it's unclear what type of information this form would contain.

D. Client care Kardex:

This is the correct answer. The Client care Kardex, also known as the patient care summary or Kardex, is a document that consolidates key information about a client's care, including diagnoses, treatments, procedures, and other relevant details. It provides a snapshot of the client's current status and facilitates communication among healthcare providers.

A. Flush the tube with 5 mL of water. B. Test the pH of fluid aspirated from the tube. C. Inject air through the tubing and auscultate for gurgling sounds: D. Change the bag and tubing system every 12 hr

Correct Answer is B

Explanation

A. Flush the tube with 5 mL of water:

Explanation: Flushing the tube with water is a routine practice before and after administering medications or feedings to maintain tube patency. However, it is not the primary action to confirm tube placement.

B. Test the pH of fluid aspirated from the tube (Correct Answer):

Explanation: Testing the pH of aspirated fluid helps confirm that the tube is in the stomach. A pH between 1 and 5 is generally indicative of gastric placement.

C. Inject air through the tubing and auscultate for gurgling sounds:

Explanation: This method is an older practice and is not recommended as a reliable method for verifying tube placement. Testing the pH is a more accurate and preferred method.

D. Change the bag and tubing system every 12 hr:

Explanation: Changing the bag and tubing system every 12 hours is a routine practice to maintain the integrity of the enteral feeding system. However, it is not specifically related to the initial steps in verifying tube placement.

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A murse is caring for an older adult client who has advanced dementia and needs a blood transfusion. The client previously designated her ad daughter on a durable power of attorney for health care form, and the daughter refuses the treatment. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

A nurse is accessing computerized data about a client recently transferred to a step-down unit. Which of the following forms should provide the nurse with the most comprehensive client information?

Correct Answer is D

Explanation

A nurse is preparing to administer an intermittent enteral feeding through a small-bore NG tube. Which of the following actions should the nurse take before initiating the feeding?

Correct Answer is B

Explanation

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A murse is caring for an older adult client who has advanced dementia and needs a blood transfusion. The client previously designated her ad daughter on a durable power of attorney for health care form, and the daughter refuses the treatment. Which of the following actions should the nurse take?

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