A nurse is assisting with the care of a client.
Laboratory Results
Abdominal ultrasound: mass present in small intestine proximal to the ileocecal valve. The size of mass is 6 cm x 7
cm (2.4 in x 2.8 in).
Select the 4 responsibilities the nurse has in relation to the client's advance directives.
Inform the client that an advance directive discontinues further care.
Initiate a power of attorney for health care documents.
Document that the provider discussed do-not-resuscitate status with the client.
Provide the client with written information about advance directives.
Communicate advance directives status via the medical record and shift report.
Instruct the client that an advance directive is a legal document and must be honored by care providers.
Correct Answer : C,D,E,F
A. Inform the client that an advance directive discontinues further care. This statement is incorrect. An advance directive does not discontinue further care but outlines the client's preferences for medical treatment if they become unable to communicate their wishes.
B. Initiate a power of attorney for health care documents. This is not the nurse's responsibility. Initiating a power of attorney for health care documents typically involves legal consultation, and the client should be referred to appropriate resources.
C. Document that the provider discussed do-not-resuscitate status with the client. This is correct. The nurse should document that the provider has discussed DNR (Do Not Resuscitate) status with the client, ensuring that the discussion and decision are clearly recorded in the medical record.
D. Provide the client with written information about advance directives. This is correct. The nurse is responsible for providing the client with written information about advance directives, ensuring the client understands their rights and options.
E. Communicate advance directives status via the medical record and shift report. This is correct. The nurse must ensure that the client's advance directive status is clearly communicated in the medical record and during shift reports to ensure continuity of care.
F. Instruct the client that an advance directive is a legal document and must be honored by care providers. This is correct. The nurse should inform the client that an advance directive is a legal document that healthcare providers are required to honor, according to the client's wishes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Waiting 1 minute between suctioning attempts allows the client to recover and ensures that the procedure is not overly invasive. It also helps to prevent the client from becoming hypoxic.
The distance that the nasopharyngeal catheter should be inserted varies from person to person and therefore 10 cm is not standard.
During nasopharyngeal suctioning, the nurse should apply suction intermittently while withdrawing the catheter, not during insertion. Applying suction during insertion can cause tissue damage and increase the risk of trauma.
The nurse should also apply intermittent suction for no longer than 15 seconds to prevent hypoxia and damage to the mucosal lining. Suctioning for an extended period can cause discomfort and harm to the client.
Correct Answer is ["B","C","D"]
Explanation
It is not appropriate for the nurse to threaten the client's child with reporting for maltreatment without further assessment and evidence.
Asking the client's child to provide details regarding the client's fractured arm will provide additional information about the client's injury and help the nurse assess the potential for abuse or neglect.
Discussing respite care options with the client's child may help alleviate any caregiver stress or burden, and ensure the client's continued care and safety.
Speaking to the client privately will help establish trust and rapport, and allow the client to disclose any
concerns or issues that they may not feel comfortable sharing in front of their child.
Providing legal advice regarding power of attorney is not within the scope of nursing practice and should be referred to a legal professional. Additionally, the client's capacity to make decisions and appoint a power of attorney should be assessed before providing such advice.
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