A nurse is preparing to administer eye drops to a child.

Which of the following actions should the nurse take?

b, d, e, and f.

b. Initiate a power of atorney for health care document: One of the primary responsibilities of a nurse in relation to advance directives is to initiate the process of creating an advance directive. This includes assisting the client in completing a power of atorney for health care document, which designates a person to make healthcare decisions for the client if they are unable to do so.

d. Provide the client with writen information about advance directives: It is important for the nurse to provide the client with writen information about advance directives, including their rights and options for creating an advance directive. This information should be provided in a clear and understandable manner.

c. Communicate advance directives status via the medical record and shift report: The nurse should communicate the client's advance directives status to other members of the healthcare team via the medical record and shift report. This ensures that everyone involved in the client's care is aware of the client's wishes and can provide care that is consistent with those wishes.

f. Instruct the client that an advance directive is a legal document and must be honored by care providers: The nurse should instruct the client that an advance directive is a legal document that must be honored by care providers. This ensures that the client understands the importance of their advance directive and can advocate for their wishes if necessary.

a. Inform the client that an advance directive discontinues further care: This option is incorrect. An advance directive does not automatically discontinue further care. It simply provides guidance to healthcare providers on the client's wishes for medical treatment. It is important for the nurse to explain this to the client and ensure that they understand the purpose of an advance directive.

c. Document that the provider discussed do-not-resuscitate status with the client: This option is also incorrect. While discussing do-not-resuscitate status may be part of the advance directive process, it is not one of the primary responsibilities of the nurse in relation to advance directives. The nurse should ensure that the client's wishes regarding resuscitation are documented in their advance directive, but they do not need to document that the provider discussed this topic with the client.

Choice A Reason:

Applying warm, moist packs to the surgical site may not be indicated as it can potentially increase swelling and disrupt the surgical site.

Choice B Reason:

Massaging the lower leg in smooth, long strokes is generally not recommended in the early postoperative period, as it can disturb the surgical site and potentially lead to complications.

Choice C Reason:

When planning care for a client who is postoperative following a knee arthroplasty, placing a pillow under the surgical knee can be beneficial. This helps maintain proper alignment, reduces pressure on the surgical site, and promotes comfort and circulation. Elevating the leg slightly with a pillow can also help reduce swelling and minimize the risk of complications such as deep vein thrombosis (DVT).

Choice D Reason:

Using the continuous passive-motion (CPM) machine intermittently should be done as ordered by the healthcare provider and under their guidance.CPM is typically initiatedearly postoperatively, often within the first 24 hours after surgery.