A nurse is caring for a client who has an end-stage lung disease. The client requests not to be resuscitated if their condition worsens. Which of the following actions should the nurse take?
Explain to the client what it means to change their code status.
Place a sign with “Do Not Resuscitate” outside the client’s room.
Obtain consent from the family to change the plan of care.
Document the client’s request in the medical record.
Correct Answer : A,D
Choice A reason: Explaining the implications of a Do Not Resuscitate (DNR) status ensures the client understands that no CPR or intubation will occur if their condition deteriorates. This supports informed consent and autonomy, clarifying the scope of DNR to prevent misunderstandings. It respects the client’s decision-making capacity, ensuring their wishes align with end-of-life care preferences.
Choice B reason: Placing a “Do Not Resuscitate” sign outside the room breaches confidentiality under HIPAA, risking unauthorized disclosure of sensitive information. DNR status is communicated via medical records or wristbands. This action is inappropriate, as it does not contribute to implementing the client’s wishes and violates privacy standards, making it an incorrect response.
Choice C reason: Obtaining family consent is unnecessary for a competent client’s DNR request, as autonomy rests with the client. If decisionally capable, their wishes override family input. The nurse’s role is to support the client’s decision, not seek family approval, unless the client is incapacitated, which is not indicated, making this action inappropriate.
Choice D reason: Documenting the DNR request in the medical record ensures the care team follows the client’s wishes, preventing unwanted interventions. Accurate documentation communicates code status, supports legal and ethical standards, and ensures continuity of care. This is critical for aligning treatment with the client’s end-of-life preferences, making it a necessary action.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Informing the client that consent cannot be withdrawn is incorrect, as clients can revoke consent at any time before or during the procedure. This misrepresents patient rights, making it an unethical and illegal statement for the nurse’s role.
Choice B reason: Identifying risks or discomforts is the surgeon’s responsibility, not the nurse’s, during consent. The nurse verifies understanding and voluntariness, not provides risk details, so this action is outside the nurse’s scope, making it incorrect.
Choice C reason: Ensuring the client understands the procedure and voluntarily agrees is the nurse’s role when witnessing consent. This verifies informed, autonomous decision-making, aligning with legal and ethical standards, making it the correct responsibility for the nurse.
Choice D reason: Providing a detailed surgical technique explanation is the surgeon’s role, not the nurse’s. The nurse ensures comprehension and consent, not technical details, so this action exceeds the nurse’s scope during consent, making it incorrect.
Correct Answer is B
Explanation
Choice A reason: Nurses can witness advance directives in many settings, depending on state laws, so stating they cannot is inaccurate. This response dismisses the client’s request without providing guidance, making it incorrect and unhelpful for addressing their wishes.
Choice B reason: Including the client’s desire for advance directives in the medical record ensures their wishes are documented and respected. This aligns with the Patient Self-Determination Act, facilitating care planning, making it the correct and supportive response.
Choice C reason: Stating the client’s name can be removed from advance directives is confusing, as directives are personal and revocable, not about name removal. This response is inaccurate and irrelevant to the client’s request, making it incorrect.
Choice D reason: There is no universal age requirement of 21 for advance directives; competent adults (typically 18+) can create them. This statement is incorrect and restrictive, misinforming the client about their rights, making it inappropriate.
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