A nurse is assisting with the care of a client. Select

A nurse is assisting with the care of a client.

Select the 4 responsibilities the nurse has in relation to the client's advance directives.

Initiate a power of attorney for health care document.

Provide the client with written information about advance directives.

Document that the provider discussed do-not-resuscitate status with the client.

Instruct the client that an advance directive is a legal document and must be honored by care providers.

Communicate advance directives status via the medical record and shift report.

Inform the client that an advance directive discontinues further care.

Answer and Explanation

Correct Answer : B,C,D,E

Initiate a power of attorney for health care document: Nurses do not initiate or create legal documents like a power of attorney. The client must initiate this, often with legal assistance if needed.
Provide the client with written information about advance directives: It is the nurse’s responsibility to ensure the client receives clear, written information about advance directives, including explanations of living wills, DNR orders, and medical power of attorney documents.
Instruct the client that an advance directive is a legal document and must be honored by care providers: Nurses reinforce that advance directives are legally binding documents. They ensure the client's wishes are respected by the healthcare team throughout their care.
Communicate advance directives status via the medical record and shift report: Once a client’s advance directive status is known, it must be accurately documented and communicated to all healthcare providers to ensure continuity and adherence to the client’s wishes.
Document that the provider discussed do-not-resuscitate status with the client: Nurses are responsible for documenting that the conversation regarding DNR status occurred, including who had the conversation and the client's stated wishes, even though the actual discussion is led by the provider.
Inform the client that an advance directive discontinues further care: Advance directives do not mean that all care is discontinued. Clients can still receive comfort, palliative, or supportive treatments based on their wishes outlined in the directive.

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Correct Answer is D

Explanation

A. Fats: While fats provide energy and help with cell membrane structure, they are not the primary nutrient required to promote wound healing. Excess fat intake without proper balance may not directly aid in faster tissue repair.

B. Calcium: Calcium is important for bone health and muscle function but does not play a central role in soft tissue wound healing. It is more critical in fracture healing rather than open wound repair.

C. Vitamin D: Vitamin D supports calcium absorption and bone health. Although it contributes to immune function, it is not the main nutrient needed to directly repair skin and soft tissue wounds.

D. Protein: Protein is essential for wound healing because it supports cell growth, tissue repair, and immune function. Adequate protein intake is critical to form new tissue, promote collagen synthesis, and restore skin integrity in clients with open wounds.

A. Anorexia B. Epistaxis C. Weight gains D. Bradycardia

Correct Answer is B

Explanation

A. Anorexia: Anorexia, or loss of appetite, is not a typical adverse effect directly associated with heparin use. While it may occur due to general postoperative factors, it is not an urgent or life-threatening reaction that necessitates immediate reporting related to anticoagulant therapy.

B. Epistaxis: Epistaxis, or nosebleed, is a sign of potential bleeding complications, which is a major adverse effect of heparin. Because heparin inhibits clot formation, any evidence of spontaneous bleeding must be reported immediately to the provider to assess for potential heparin-induced bleeding disorders.

C. Weight gain: Weight gain could suggest fluid retention, but it is not a typical adverse effect of heparin. While postoperative clients should be monitored for signs of fluid imbalance, sudden bleeding signs like epistaxis are far more critical to recognize and report when administering anticoagulants.

D. Bradycardia: Bradycardia, or slow heart rate, is not commonly linked to heparin therapy. While abnormal heart rhythms may occur postoperatively for other reasons, they are not typically associated with bleeding risks from heparin and thus do not require urgent reporting specific to heparin use.

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Area assessed	Findings
Neurological	Drowsy but easy to arouse
Vital Signs	Temperature 35.3°C (95.5° F) Heart rate 60/min Respiratory rate 16/min Blood pressure 90/60 mm Hg Oxygen saturation 94% (oxygen at 2 L/min via nasal cannula) Rates pain as 1 on 0/10 pain scale.
Integumentary	Skin cool and moist to touch.
Cardiopulmonary	Heart rate regular. Pedal pulse +1 bilateral. Lungs clear bilateral. Respirations even, nonlabored.
Abdomen	Abdomen soft, nondistended. Bowel sounds hypoactive in all four quadrants. 2x2 gauze with a clear transparent dressing intact to right lower and upper abdominal quadrant. Moderate amount of sanguineous drainage noted on the lower dressing

A nurse is assisting with the care of a client.

Select the 4 responsibilities the nurse has in relation to the client's advance directives.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

Correct Answer is B

Explanation

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A nurse is assisting with the care of a client. Select the 4 responsibilities the nurse has in relation to the client's advance directives.

Nursing Test Bank

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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A nurse is assisting with the care of a client.

Select the 4 responsibilities the nurse has in relation to the client's advance directives.