A nurse is assisting with the care of a client. Laboratory Results
1100:
Abdominal ultrasound: mass present in small intestine proximal to ileocecal valve. 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.
Provide the client with written information about advance directives
Instruct the client that an advance directive is a legal document and must be honored by care providers
Initiate a power of attorney for health care document
Communicate advance directives status via the medical record and shift report
Document that the provider discussed-do-not-resuscitate status with the client
Inform the client that an advance directive discontinues further care
Correct Answer : A,B,C,D
Provide the client with written information about advance directives: It is important for the nurse to educate the client about advance directives, their purpose, and how they can make informed decisions about their healthcare.
Instruct the client that an advance directive is a legal document and must be honored by care providers: The nurse should explain to the client that an advance directive is a legally binding document that guides healthcare decisions, and it must be respected and followed by healthcare providers.
Communicate advance directives status via the medical record and shift report: The nurse should ensure that the client's advance directives status is accurately documented in the medical record and communicated to other members of the healthcare team during shift handoffs. This helps ensure that the client's wishes are known and respected by all involved in their care.
Initiate a power of attorney for health care document: The nurse can assist the client in initiating a power of attorney for healthcare document if the client wishes to appoint someone as their healthcare proxy or agent. This document designates someone to make medical decisions on behalf of the client if they become unable to do so.
The other options listed are not appropriate or accurate in relation to the responsibilities of the nurse regarding advance directives:
Document that the provider discussed-do-not-resuscitate status with the client: While discussing do-not-resuscitate (DNR) status may be part of the advance care planning process, it is not directly related to advance directives as a whole.
Inform the client that an advance directive discontinues further care: This statement is incorrect and misleading. An advance directive does not automatically discontinue care but rather guides the provision of care according to the client's wishes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
During an intravenous pyelogram (IVP), a contrast dye is injected into the client's veins, and X-ray images are taken to visualize the urinary tract. The dye used in an IVP can cause a warming or flushing sensation as it circulates through the body. The client's statement indicates an understanding of this common sensation associated with the procedure.
"I can have a meal up to 2 hours before the procedure": This statement is incorrect. Typically, for an IVP, the client is required to have an empty stomach before the procedure to ensure accurate imaging results. The client should follow the specific instructions provided by their healthcare provider regarding fasting before the procedure.
"I do not need to sign a consent form before this procedure": This statement is incorrect. Informed consent is required for most medical procedures, including an IVP. The client should sign a consent form after receiving all the necessary information about the procedure, its risks, and benefits.
"I should limit my fluid intake for 2 days after the procedure": This statement is incorrect. After an IVP, it is generally advised to increase fluid intake to help flush out the contrast dye from the body and prevent potential complications. The client should follow the specific instructions provided by their healthcare provider regarding post-procedure fluid intake.
Correct Answer is C
Explanation
Orthostatic hypotension, which is a sudden drop in blood pressure upon standing, can be a side effect of enalapril and may lead to syncope. Instructing the client to rise slowly from a sitting to a standing position helps minimize the risk of a sudden drop in blood pressure and decreases the chances of syncope occurring.
Decreasing fluid intake is not likely to be the cause of syncope related to enalapril. It is important for clients to maintain adequate hydration, especially if they are experiencing side effects such as orthostatic hypotension.
While a low pulse rate may indicate bradycardia, it is not the primary concern in this situation. Orthostatic hypotension leading to syncope is the main issue, and the client should be instructed to rise slowly to prevent it.
While enalapril is an angiotensin-converting enzyme (ACE) inhibitor that can increase potassium levels in the blood, it is not directly related to syncope. Dietary changes should be made under the guidance of a healthcare provider based on individual needs and blood test results.
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