A nurse is developing a plan of care for a client who has chronic kidney disease. The client gives the nurse copies of their advance directives which state that they do not want to begin dialysis. Which of the following actions should the nurse include in the plan?
Document within the medical record that the client has advance directives in place.
Place a do-not-resuscitate (DNR) bracelet on the client.
Ask the client to sign an Against Medical Advice (AMA) form.
Ensure the client's family is aware of the treatment decisions within the advance directives.
The Correct Answer is A
Rationale:
A. This option is correct because the nurse should document that the client has advance directives in place and specify the treatment preferences, including the refusal of dialysis. Accurate documentation ensures that all members of the healthcare team are aware of the client’s wishes and that care aligns with ethical and legal standards.
B. This option is incorrect because a do-not-resuscitate (DNR) order pertains specifically to withholding cardiopulmonary resuscitation in the event of cardiac or respiratory arrest. Advance directives regarding dialysis refusal do not automatically imply a DNR order.
C. This option is incorrect because an Against Medical Advice (AMA) form is used when a client chooses to leave the facility against medical advice, not when they are making informed decisions about specific treatments. Refusing dialysis per advance directives is not the same as leaving AMA.
D. This option is incorrect because while discussing advance directives with family members can be helpful, the client’s preferences take precedence. The nurse should respect the client’s autonomy and ensure that the plan of care reflects their documented wishes, regardless of family opinion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. This option is correct because applying moisturizing lotion after bathing helps maintain skin integrity, prevents dryness and cracking, and reduces the risk of pressure injuries. Proper skin care is a key preventive measure for clients who are immobile.
B. This option is incorrect because massaging bony prominences is not recommended; it can actually cause tissue damage and increase the risk of pressure injury. Instead, gentle repositioning and pressure-relief techniques should be used.
C. This option is incorrect because maintaining the head of the bed at a 45° angle increases pressure on the sacral area, heightening the risk for pressure injuries. The head of the bed should generally be kept at 30° or less when possible to reduce shear and pressure on bony prominences.
D. This option is incorrect because contact isolation is not a preventive measure for pressure injuries. It is used for clients with infectious conditions to prevent transmission, not for immobility-related skin protection.
Correct Answer is D
Explanation
Rationale:
A. This option is incorrect because an assisted living facility provides long-term housing with support for activities of daily living, but it is not designed to offer short-term relief for a caregiver managing a terminally ill client at home.
B. This option is incorrect because social services can provide guidance on resources and financial assistance, but they do not provide direct, temporary care for the client while the primary caregiver attends to personal needs.
C. This option is incorrect because a spiritual support person can provide emotional and spiritual guidance but does not offer physical care or supervision for the client.
D. This option is correct because respite care provides temporary relief for primary caregivers by offering short-term, supervised care for the client. This allows the caregiver to attend personal errands, rest, or manage other responsibilities while ensuring the client continues to receive safe, quality care at home. Respite care is especially important for caregivers managing clients with advanced illnesses.
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