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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Constipation is not a common or expected side effect of cefazolin and is not typically associated with this medication.
B. Elevated skin patches are not a known side effect of cefazolin and would not typically occur as a result of taking this medication.
C. Ringing in the ears (tinnitus) is a potential adverse effect of cefazolin and should be reported to the provider because it may indicate ototoxicity, which can be serious.
D. Depression is not a common side effect of cefazolin and is not typically associated with this medication.

A. "The machine is programmed to prevent you from administering more than a safe dose." B. "During medication administration, you will not be able to move your legs freely." C. "This method of pain control will shorten the second stage of labor." D. "This type of anesthesia commonly causes a postpartum headache."

Correct Answer is B

Explanation

- Choice A Rationale: The epidural PCA (patient-controlled analgesia) is designed with safety mechanisms to ensure that the patient cannot administer a dose that exceeds the prescribed safe limit. This is crucial to prevent potential overdose and complications associated with high doses of analgesics.
- Choice B Rationale: While it is true that some patients may experience reduced mobility in their legs during epidural analgesia, this is not an absolute and can vary based on the dosage and individual response. Therefore, it is not a guaranteed effect and should not be presented as such.
- Choice C Rationale: There is no conclusive evidence to suggest that epidural pain control methods shorten the second stage of labor. In fact, some studies indicate that it may actually prolong it. The primary purpose of epidural PCA is pain management, not altering the labor process timeline.
- Choice D Rationale: Postpartum headaches can be a side effect of epidural anesthesia, but they are not common to all cases. It is associated with a complication known as a post-dural puncture headache, which occurs in a minority of cases. Hence, it should not be stated as a common outcome.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is B

Explanation

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