A nurse is assisting with the care of a client.
Nurses' Notes
1000
Client states, "I am tired of undergoing treatment because it doesn't seem to be working." Client states, "I hope I am just constipated." Appendectomy scar on right lower quadrant. Abdomen is soft, tender in right lower quadrant, bowel sounds present in all four quadrants.
1200
Surgeon has notified the client that surgical removal of the mass is advisable due to the client's history of metastasis and ongoing treatment failure. The client and their partner want to discuss end-of-life care. Client states, "I am unsure what it means to have a living will or a do-notresuscitate order." The client's partner states, " don't understand what power of attorney means. Both client and partner indicate that they might wish to decline further treatment as well as further fesaving measures should they become necessary. The partner states "How can we be sure that our decision about care will be honored?"
Select the 4 responsibilities the nurse has in relation to the client's advance directives.
Communicate advance directives status via the medical record and shift report.
Document that the provider discussed do-not-resuscitate status with the client
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
Inform the client that an advance directive discontinues further care.
Facilitate a power of attorney for health care document.
Correct Answer : A,B,C,F
The nurse is responsible for educating the client and their partner about advance directives and facilitating their decision-making process. Advance directives are legal documents that allow the client to express their preferences for medical care and treatments at the end of life.
They also enable the client to appoint a health care proxy, who is a person who can make health care decisions for the client if they are unable to do so themselves.
The nurse should provide the client with written information about advance directives, document that the provider discussed do-notresuscitate status with the client, and communicate advance directives status via the medical record and shift report.
The nurse should not instruct the client that an advance directive is a legal document and must be honored by care providers, as this may imply coercion or limit the client's right to change their mind.
The nurse should also not inform the client that an advance directive discontinues further care, as this is inaccurate and may discourage the client from completing one.
The nurse should facilitate a power of attorney for health care document only if the client wishes to designate a health care proxy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is A. The nurse should apply pressure to the lacrimal punctum, which is located at the inner corner of each eye, after administering eye drops to prevent systemic absorption of the medication and reduce side effects. The nurse should position the child supine or sitting with their head tilted back slightly before administering eye drops, as this allows for easier instillation and prevents spillage of medication. The nurse does not need to flush the eye with normal saline solution before administering eye drops, unless there is debris or discharge in the eye that needs to be removed. The nurse should wipe from the inner to the outer canthus after administering eye drops, as this prevents contamination of the eye and reduces the risk of infection.
Correct Answer is C
Explanation
The client should wrap the leg with an elastic bandage to reduce swelling and promote healing.
The client should not maintain bed rest, as this can increase the risk of thrombosis and infection.
The client should elevate the leg above the heart level, not keep it in a dependent position, as this can reduce venous pressure and edema.
The client does not need to implement a sodium-restricted diet, as this is not related to vein stripping.
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