An older adult male who is in his early 70's is admitted to the emergency department because of a COPD exacerbation. The client is struggling to breathe and the healthcare team is preparing for endotracheal intubation. The spouse's wife, who is 30 years younger than the client, asks the nurse to stop the procedure and provides the nurse a copy of the client's living will. Which action should the nurse take?

Alert the nursing staff of the client's do not resuscitate status.

Facilitate a family meeting with the palliative care team.

Notify the healthcare provider of the client's wishes.

Place a certified copy of the living will in the client's record.

Answer and Explanation

The Correct Answer is C

Rationale

A. A living will often includes directives regarding life-sustaining treatments, including intubation. If the living will explicitly states a preference against intubation, the nurse should ensure this information is known to the healthcare team. However, a living will does not automatically imply a DNR status unless specifically stated.

B. When a living will is presented, and decisions need to be made regarding life-sustaining treatments like intubation, it is appropriate to facilitate a family meeting. In this meeting, the healthcare team, including palliative care specialists if available, can discuss the client's wishes as outlined in the living will. The goal is to ensure everyone understands the client's preferences and to make informed decisions about the course of treatment.

C. The nurse should notify the attending healthcare provider about the existence of the client's living will and its directives regarding medical interventions such as intubation. The healthcare provider needs to be aware of the client's wishes to guide the decision-making process and ensure appropriate care is provided according to the client's preferences.

D. It is crucial to ensure that the living will, once verified and certified as authentic, is placed in the client's medical record. This document serves as a legal and ethical guide for healthcare decisions, especially during critical situations like an exacerbation requiring intubation.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is B

Explanation

Rationale

A. Applying ice or a warm compress without assessing the site could potentially worsen any underlying issue.

B. The appropriate intervention would be to discontinue the IV site after ensuring a new access is established. This is because continuing to use a painful IV site can lead to complications such as infiltration or phlebitis.

C. Redressing the site without assessment does not address the client's complaint of pain.

D. Checking the medical record provides information about when the IV was inserted, which can be important for assessing the site's viability and expected duration. However, it doesn't address the immediate concern of the client's pain at the site or refusal of a flush.

A. Drink electrolyte fluid replacements. B. Resume normal physical activity. C. Give a dose of regular insulin as prescribed. D. Measure urine output over the next 24 hours.

Correct Answer is C

Explanation

Rationale

A. This option may seem reasonable, as dehydration and electrolyte imbalances are concerns in DKA. However, simply drinking electrolyte fluids without addressing the underlying cause of DKA (which is insulin deficiency) would not effectively manage the condition.

B. Physical activity may exacerbate DKA if insulin levels are inadequate. It is important to stabilize blood glucose levels and manage DKA before engaging in physical activity.

C. In DKA, there is an absolute or relative deficiency of insulin, leading to hyperglycemia and ketosis. Regular insulin helps to lower blood glucose levels and inhibit further breakdown of fats into ketones, thereby correcting the metabolic imbalance associated with DKA.

D. Monitoring urine output is important in assessing hydration status, but it does not address the immediate need to manage DKA. This action alone would not correct the underlying cause of increased thirst in DKA.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While preparing to administer a scheduled IV medication, the client tells the nurse that the IV site hurts and refuses to allow the nurse to administer a flush to assess the site. Which intervention should the nurse implement?

Correct Answer is B

Explanation

When developing a teaching plan for a client with newly diagnosed type 1 diabetes mellitus, the nurse should explain that an increased thirst is an early sign of diabetic ketoacidosis (DKA). Which action should the nurse instruct the client to implement if this sign of DKA occurs?

Correct Answer is C

Explanation

A client is admitted to the intensive care until (ICU) with a spinal cord injury following a motor vehicle collision. Which nurse should be contacted to coordinate the progression of the client's care?

The nurse is preparing a client for an outpatient thoracentesis. Which statement made by the client should the nurse recognize as needing additional education?

Following laser trabeculoplasty surgery for open-angle glaucoma, the client reports acute pain deep within the eye. Which action should the nurse take?

The nurse is preparing for discharge a client with a history of celiac disease who now has developed multiple sclerosis. Which instruction is most important for the nurse to include in the discharge teaching plan?

Exhibits The nurse reviews the healthcare providers (HCP) prescription for clonazepam and gives the medication as prescribed. Which nursing intervention(s) is/are appropriate for the client starting clonazepam? Select all that apply.

While taking vital signs, a critically ill male client grabs the nurse's hand and asks the nurse not to leave. What action is best for the nurse to take?

The parent of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The parent reports no evidence of watery stools. Which nursing intervention should the nurse implement?