An older adult woman with end stage heart disease is alert and oriented and states that she does not want any heroic measures taken in the event she stops breathing. The client's children tell the nurse that they accept their mother's wishes and do not want to watch her suffer. Which action should the nurse take first?
Consult the palliative care team.
Obtain a do not resuscitate prescription.
Define the term heroic measures.
Coordinate a family conference.
The Correct Answer is B
Choice A reason: Consulting the palliative care team is an important action for the nurse to take, but not the first one. The palliative care team can provide holistic and compassionate care to the client and the family and help them cope with the end-of-life issues. However, the nurse should first obtain a do not resuscitate prescription from the healthcare provider to ensure that the client's wishes are respected and followed.
Choice B reason: Obtaining a do not resuscitate prescription is the first action for the nurse to take. The do not resuscitate prescription is a legal document that states that the client does not want any cardiopulmonary resuscitation or other life-sustaining interventions in the event of cardiac or respiratory arrest. The nurse should obtain the prescription from the healthcare provider and document it in the client's chart. The nurse should also inform the staff and the family about the prescription and its implications.
Choice C reason: Defining the term heroic measures is not the first action for the nurse to take. The term heroic measures is vague and subjective and may mean different things to different people. The nurse should clarify with the client and the family what they consider as heroic measures and what they want to avoid or accept. However, the nurse should first obtain a do not resuscitate prescription to ensure that the client's wishes are legally binding and clear.
Choice D reason: Coordinating a family conference is not the first action for the nurse to take. The family conference is a meeting where the client, the family, the healthcare provider, and the nurse can discuss the goals and plans of care and address any concerns or questions. The family conference can facilitate communication and decision-making and promote mutual understanding and support. However, the nurse should first obtain a do not resuscitate prescription to ensure that the client's wishes are honored and communicated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: The client is grieving normally in response to her husband's death and hospitalization is not necessary is not the best information for the nurse to provide this family. This may be insensitive and dismissive of the family's concerns and the client's condition. The client may have signs of delirium or dementia that require further evaluation.
Choice B reason: Managed care providers have mandatory pre-certification requirements for hospitalization is the best information for the nurse to provide this family. This informs the family of the process and criteria that need to be met before the client can be admitted to the hospital under the managed healthcare plan. This may help the family understand the limitations and expectations of the plan.
Choice C reason: Healthcare costs are escalating because clients want to have diagnostic testing conducted in the hospital is not the best information for the nurse to provide this family. This may be inaccurate and irrelevant to the family's situation. The family may not care about the healthcare costs as much as the client's well-being.
Choice D reason: Managed healthcare plans do not pay for any in-hospital medical evaluations is not the best information for the nurse to provide this family. This may be false and misleading. Managed healthcare plans may cover some in-hospital medical evaluations depending on the plan and the client's condition.
Correct Answer is C
Explanation
The correct answer is c. The client who has pneumonia following a total knee replacement, and is receiving clarithromycin orally.
Choice A reason: This client has a complex wound care and an intravenous antibiotic therapy, which require the skills and knowledge of a registered nurse. Therefore, this client should not be assigned to a PN.
Choice B reason: This client has a chronic condition that does not require frequent assessment or intervention. Therefore, this client can be assigned to a UAP under the supervision of a nurse.
Choice C reason: This client has a stable condition that can be managed with oral medication and routine monitoring. Therefore, this client can be assigned to a PN who can administer oral drugs and report any changes to the nurse.
Choice D reason: This client has a high risk of aspiration and complications due to the enteral feeding and the neurological impairment. Therefore, this client should not be assigned to a PN.
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