A nurse is participating in the care of a client as a member of the interprofessional team.

Which of the following actions should the nurse take? Select all that apply.

Document a nurse's note in the client's electronic medical record (EMR).

Modify the client's plan of care.

Document this as a negative variance in the critical pathway.

Discontinue critical pathway.

Initiate discharge summary documentation.

Answer and Explanation

Correct Answer : A,B,C

Rationale:

A. This option is correct because all significant changes in the client’s condition, including the sudden deterioration and intubation, must be documented accurately in the EMR. Thorough documentation ensures continuity of care, legal protection, and communication among the interprofessional team.

B. This option is correct because the client’s sudden deterioration and need for mechanical ventilation require immediate revision of the care plan. Updates should include new interventions, monitoring requirements, and goals relevant to the client’s current status, ensuring safe and appropriate care.

C. This option is correct because a negative variance occurs when the client’s actual progress deviates from the expected outcomes outlined in the critical pathway. The client’s sudden respiratory failure represents a deviation that should be recorded to guide future care planning and quality improvement.

D. This option is incorrect because the critical pathway should not be discontinued; it remains a guide for expected outcomes. Instead, variances should be documented, and the pathway adjusted as appropriate.

E. This option is incorrect because the client is acutely unstable and requires ongoing intensive care. Discharge summary documentation is premature and not relevant at this point.

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Correct Answer is A

Explanation

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.

A. Red B. Yellow C. Green D. Black

Correct Answer is C

Explanation

Rationale:

A. This option is incorrect because a red tag is reserved for clients with life-threatening injuries who need immediate medical intervention to survive. Examples include severe hemorrhage, airway compromise, or major trauma affecting vital organs. An ankle sprain does not pose a threat to life and does not require urgent treatment, so assigning a red tag would misallocate critical resources.

B. This option is incorrect because a yellow tag is used for clients with serious injuries that require care but are not immediately life-threatening. These clients may have fractures or moderate internal injuries that can tolerate a short delay in treatment. While more serious than a minor sprain, an ankle sprain does not meet the criteria for a yellow tag.

C. This option is correct because a green tag is applied to clients who have minor, non-life-threatening injuries. These individuals, often called "walking wounded," include those with minor sprains, abrasions, small lacerations, or mild contusions. Green-tagged clients can wait for treatment while healthcare resources are directed toward patients with more critical needs, which is a key principle of triage during disasters.

D. This option is incorrect because a black tag indicates clients who are deceased or have injuries so severe that survival is unlikely, even with immediate intervention. An ankle sprain is a minor injury with no threat to life, making the black tag inappropriate.

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A nurse is participating in the care of a client as a member of the interprofessional team. Which of the following actions should the nurse take? Select all that apply.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

Explanation

While a nurse manager is conducting a disaster-preparedness drill, they observe nurses applying triage tags to clerical staff who are posing as injured clients. The manager should expect the nurses to apply which of the following tags to a client who has an ankle sprain?

Correct Answer is C

Explanation

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A nurse is participating in the care of a client as a member of the interprofessional team.

Which of the following actions should the nurse take? Select all that apply.