A nurse is admitting a client who is scheduled for an elective surgery. Which of the following actions should the nurse take to verify the status of the client's advance directives?
Ask the client whether they have advance directives.
Refer to the client's identification card for their advance directives status.
Verify the client's advance directives with their health care surrogate.
Check for a written do-not-resuscitate prescription in the client's medical record.
The Correct Answer is A
A. Ask the client whether they have advance directives: Directly asking the client ensures that the nurse obtains accurate and up-to-date information regarding the client's advance directives.
B. Refer to the client's identification card for their advance directives status: While some clients may carry identification cards indicating their advance directives status, relying solely on this information may not be comprehensive or up-to-date.
C. Verify the client's advance directives with their health care surrogate: This step may be necessary if the client is incapacitated or unable to communicate, but it should not replace direct communication with the client.
D. Check for a written do-not-resuscitate prescription in the client's medical record: While checking the medical record is important, advance directives may include more comprehensive instructions beyond do-not-resuscitate orders, so direct communication with the client is essential.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. An increase in calf size can be a sign of deep-vein thrombosis (DVT), but it is not specific to
DVT and can occur with other conditions such as edema.
B. Capillary refill of 2 seconds is within the expected range and is not indicative of DVT.
C. A palpable cord-like vein is a classic sign of DVT and should be further assessed and reported for appropriate intervention.
D. An extremity feeling cool to the touch can be a sign of impaired circulation but is not specific to DVT and can occur with other vascular conditions.
Correct Answer is A
Explanation
A. This is the correct answer. Flushing the tubing with water after medication administration ensures that the medication reaches the stomach and prevents any residue from remaining in the tubing.
B. Clamping the tubing is not typically necessary after medication administration and may impede the flow of subsequent medications or enteral feedings.
C. While checking the patency of the tubing is important before medication administration, it is not specifically performed after administering the medication.
D. Aspirating the tubing after medication administration is not necessary and may disrupt the delivery of the medication into the stomach.
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