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.
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Related Questions
Correct Answer is D
Explanation
Rationale for A: Delegating complicated tasks to an RN might not always be appropriate, especially if the task falls within the scope of the newly licensed nurse. Time management involves prioritizing and organizing tasks effectively, not shifting responsibility unnecessarily.
Rationale for B: Documenting all client care at the end of the shift can lead to missed or inaccurate documentation. It is more efficient to document in real-time or shortly after completing tasks, ensuring accuracy and preventing a backlog of work.
Rationale for C: Performing quick tasks before time-consuming ones may lead to neglecting critical or urgent tasks. Time-consuming tasks might be of higher priority and should be addressed based on urgency rather than the time they take.
Rationale for D: Completing one task before moving on to the next allows the nurse to focus on each task fully, reducing the chance of errors and ensuring that all tasks are completed systematically. This approach improves efficiency and task management.
Correct Answer is D
Explanation
A. Celiac disease is an autoimmune disorder characterized by intolerance to gluten, a protein found in wheat, barley, and rye. It is not directly related to excessive milk consumption.
B. Lactose intolerance is a condition in which the body is unable to digest lactose, the sugar found in milk and dairy products. Excessive milk consumption could exacerbate symptoms in individuals with lactose intolerance, but it is not the primary concern in this scenario.
C. Acute renal failure is not directly related to excessive milk consumption in an otherwise healthy toddler.
D. Excessive milk consumption can interfere with iron absorption from other foods, leading to iron-deficiency anemia, especially if the child's overall diet is poor or lacks sources of iron.
Therefore, this practice places the toddler at risk for iron-deficiency anemia.
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