A nurse is educating a terminally ill patient about declining resuscitation in a living will.
The patient asks, “What would happen if I arrived at the emergency department and I had difficulty breathing?” Which of the following responses should the nurse make?
“We would give you oxygen through a tube in your nose.”.
“You would be unable to change your previous wishes about your care.”.
“We would insert a breathing tube while we evaluate your condition.”.
“We would consult the person appointed by your health care proxy to make decisions.”. .
The Correct Answer is A
Choice A rationale
If a patient with a living will arrived at the emergency department with difficulty breathing, the healthcare team would provide immediate care to ease the patient’s distress, such as administering oxygen.
Choice B rationale
While a living will outlines a patient’s wishes for end-of-life care, it does not prevent the patient from receiving immediate, necessary care in an emergency situation.
Choice C rationale
Inserting a breathing tube may be necessary in some cases, but it would not be the first step in managing difficulty breathing.
Choice D rationale
While the healthcare team would consult the person appointed by the patient’s healthcare proxy to make decisions, immediate care would not be delayed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While colonoscopy is a screening method for colon cancer, it is not typically recommended to begin at age 60 for individuals at average risk. Instead, colonoscopy screening is usually recommended to begin at age 50 and continue every 10 years if no polyps are found.
Choice B rationale
The recommendation for an average risk individual for colon cancer is to have a fecal occult blood test every year. This test checks for hidden blood in the stool, which can be an early sign of cancer.
Choice C rationale
Sigmoidoscopy every 10 years is another screening option for colon cancer. However, it only examines the rectum and lower third of the colon, whereas a colonoscopy examines the entire colon.
Choice D rationale
Blood tests are not typically used as a primary screening method for colon cancer. They may be used in conjunction with other tests, but a blood sample alone is not sufficient for screening.
Correct Answer is C
Explanation
Choice A rationale: Client 1 is admitted with a new diagnosis of rheumatoid arthritis. While this condition can cause discomfort and requires management, it is a chronic condition that does not typically present an immediate threat to the client’s health. Therefore, while this client will need to be assessed and their care plan will need to be adjusted to manage their new diagnosis, they are not the highest priority at this time.
Choice B rationale: Client 2 has a history of hyperlipidemia and has been administered Atorvastatin 20 mg PO as prescribed. Hyperlipidemia is a chronic condition that requires ongoing management, but it does not typically present an immediate threat to the client’s health. The fact that the client has been administered their medication as prescribed suggests that their condition is currently being managed effectively. Therefore, while this client will need to be monitored to ensure that their medication continues to be effective, they are not the highest priority at this time.
Choice C rationale: Client 3 is 1 day postoperative and reports pain as 8 on a scale of 0 to 10, even after Morphine 5 mg subcutaneous was administered as prescribed. This indicates that the client’s pain is not well controlled and could be a sign of complications. Therefore, immediate assessment is required. This client should be the nurse’s highest priority.
Choice D rationale: Client 4 is admitted with a new diagnosis of heart failure. Heart failure is a serious condition that can have life- threatening complications. However, the fact that this is a new diagnosis suggests that the client’s condition is not yet severe enough to require immediate intervention. Therefore, while this client will need to be assessed and their care plan will need to be adjusted to manage their new diagnosis, they are not the highest priority at this time.
Choice E rationale: Client 5 has a stage 2 pressure injury on the left heel. Pressure injuries can lead to serious complications, including infection and tissue necrosis. However, a stage 2 pressure injury is a relatively minor injury that is unlikely to present an immediate threat to the client’s health. Therefore, while this client will need to be assessed and their care plan will need to be adjusted to manage their pressure injury, they are not the highest priority at this time.
Choice F rationale: Client 6 is admitted with a new diagnosis of diabetes mellitus. Diabetes is a chronic condition that requires ongoing management. However, the fact that this is a new diagnosis suggests that the client’s condition is not yet severe enough to require immediate intervention. Therefore, while this client will need to be assessed and their care plan will need to be adjusted to manage their new diagnosis, they are not the highest priority at this time.
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