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 B
Explanation
A. The client's foot feels cooler than in the previous assessment: While decreased temperature can indicate decreased perfusion, the absence of a palpable pedal pulse is a more concerning finding.
B. The client's pedal pulse in the right foot is not palpable: This finding suggests compromised blood flow distal to the site of the bypass graft, which could indicate graft occlusion or impaired circulation.
C. The client's capillary refill time is 5 seconds in the toes: While prolonged capillary refill time can indicate impaired circulation, the absence of a palpable pedal pulse is a more concerning finding.
D. The client reports a pain level of 8 on a scale from 3 to 10: Pain is subjective and can be managed with analgesics, but the absence of a palpable pedal pulse indicates a more serious issue related to perfusion.
Correct Answer is B
Explanation
A. Disposing of used syringes in the household trash poses a risk of accidental needle sticks to others. The correct method of disposal is using a puncture-resistant container.
B. Storing the current bottle of insulin in the refrigerator is the correct practice to maintain the stability and effectiveness of the insulin. Insulin should be kept refrigerated until opened and
then can be kept at room temperature for up to 28 days.
C. Holding the needle at a 15° angle to the skin is not the recommended technique for insulin injection. The correct angle for subcutaneous insulin injection is usually 45 or 90 degrees, depending on the client's body habitus and the length of the needle.
D. Using an injection site that is 1 inch from the previous site may lead to lipohypertrophy, a condition characterized by fatty tissue buildup under the skin, which can affect insulin absorption. It is recommended to rotate injection sites to avoid this complication.
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