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. While the blood pressure reading provides information about the client's cardiovascular status, it does not specifically indicate the severity of heart failure. Therefore, it is not the most pertinent information to include in the report.
B. The potassium level is important to monitor in clients with heart failure due to the potential for electrolyte imbalances, but a specific potassium level of 4.9 mg/dL may not be immediately relevant to the client's current status. Therefore, it is not the most critical information to include in the report.
C. Pitting edema in the lower extremities is a common finding in clients with heart failure and can indicate fluid overload, a hallmark characteristic of heart failure. Including this information in the report is essential for providing an accurate picture of the client's condition and current status.
D. While assistance with meals may provide insight into the client's functional status and support system, it is not as directly related to the client's heart failure as the presence of pitting edema.
Correct Answer is C
Explanation
A. Incorrect. Allowing the baby to finish a bottle at the next feeding increases the risk of overfeeding and can lead to problems such as excessive weight gain and discomfort.
B. Incorrect. Placing the baby on their stomach after feedings increases the risk of choking and is not recommended. The correct position is to place the baby on their back to sleep.
C. Correct. Newborns typically need to be fed approximately every 2-3 hours, which amounts to about six to eight feedings per day. This statement indicates an understanding of the frequency of feeding required for a newborn.
D. Incorrect. Adding rice cereal to a newborn's bottle is not recommended, especially without medical advice, as it can increase the risk of choking and may not be developmentally appropriate.
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