A nurse is caring for a client who is 1 hr postpartum.

Nurses' Notes 1200:

Large amount of lochia rubra noted on perineal pad. Fundus boggy at two fingerbreadths above the umbilicus. Oxytocin 20 units being administered via continuous JV infusion.

1215:

Large amount of lochia rubra with several large clots noted. Client reports feeling anxious. Skin cool and clammy. Provider notified.

Select the actions the nurse should take.

- A. Calories is incorrect. Clients with Crohn's disease and enteroenteric fistula need adequate calories to prevent malnutrition and weight loss due to inflammation, malabsorption, and increased metabolic rate.

- B. Protein is incorrect. Clients with Crohn's disease and enteroenteric fistula need adequate protein to promote tissue healing and prevent protein-losing enteropathy.

- C. Potassium is incorrect. Clients with Crohn's disease and enteroenteric fistula are at risk of hypokalemia due to diarrhea, vomiting, and fistula drainage. They need to increase their potassium intake to prevent electrolyte imbalance and cardiac complications.

- D. Fiber is correct. Clients with Crohn's disease and enteroenteric fistula should decrease their fiber intake to reduce intestinal motility, bulk, and gas production, which can worsen the inflammation and fistula formation.

Choice A rationale:

While providing end-of-life education is important, it is not a specific requirement under the Patient Self-Determination Act. The act primarily focuses on ensuring that patients' wishes regarding medical treatment and interventions are respected through advance directives.

Choice B rationale:

Documenting in the client's medical record if the client has advance directives is a requirement under the Patient Self-Determination Act. This documentation ensures that healthcare providers are aware of the patient's preferences regarding medical treatment, especially in end-of-life situations. Advance directives may include living wills or durable power of attorney for healthcare, allowing patients to express their choices regarding medical interventions and appointing someone to make decisions on their behalf if they are unable to do so.

Choice C rationale:

Providing the client with a list of eligible individuals who can serve as a health care proxy is not a requirement under the Patient Self-Determination Act. While it can be helpful, the act primarily emphasizes documenting and respecting the patient's existing advance directives.

Choice D rationale:

Ensuring the client has an attorney for assistance with end-of-life documents is not a requirement under the Patient Self-Determination Act. While legal advice can be beneficial, the act primarily focuses on healthcare providers' responsibilities in documenting and respecting patients' advance directives.