An older adult woman with end-stage heart disease is hospitalized for severe heart failure (HF). She is alert, oriented, and requests that no heroic measures are implemented if her breathing stops. Which action should the nurse take first?

Consult the palliative care team about client’s care.

Set up a family conference to discuss the client’s wishes.

Obtain a “do not resuscitate” (DNR) prescription.

Discuss with the client her meaning of heroic measures.

Answer and Explanation

The Correct Answer is D

Choice A reason: Consulting the palliative care team is valuable for end-stage heart failure but not the first step. Clarifying the client’s definition of “heroic measures” ensures her wishes are accurately understood before involving specialists. Misinterpretation could lead to care misaligned with her preferences, delaying appropriate planning and support.

Choice B reason: Setting up a family conference is secondary to understanding the client’s wishes directly. Family discussions are important but premature without clarifying what “heroic measures” means to the client. Her autonomy must guide care, and miscommunication risks family conflict or decisions not reflecting her true preferences.

Choice C reason: Obtaining a DNR prescription is premature without confirming the client’s intent. “Heroic measures” may include more than resuscitation, such as ventilation or dialysis. Acting without clarification risks violating autonomy, as the client’s wishes may not align with a DNR, potentially leading to inappropriate care decisions.

Choice D reason: Discussing the meaning of “heroic measures” ensures the client’s wishes are clearly understood, respecting her autonomy. This clarifies whether she means no resuscitation, ventilation, or other interventions, guiding accurate documentation and care planning. This step is critical to align subsequent actions, like DNR orders, with her preferences.

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Correct Answer is B

Explanation

Choice A reason: Discontinuing the nasal cannula risks worsening hypoxia, as the client’s oxygen saturation is 92%. The lesion is likely from tubing pressure, not oxygen delivery. Padding addresses the skin issue without compromising oxygenation, making discontinuation an inappropriate intervention that could harm the client’s respiratory status.

Choice B reason: Placing padding around the cannula tubing prevents further pressure on the zygomatic lesion, promoting skin healing. The lesion likely results from tubing friction or pressure. This intervention maintains oxygen delivery at 4 L/minute, ensuring the client’s 92% saturation is supported while addressing the skin integrity issue effectively.

Choice C reason: Applying lubricant to the cannula tubing may reduce friction but does not address pressure causing the lesion. Lubricants are more suitable for nasal dryness. Padding is more effective, as it cushions the tubing, preventing further skin breakdown while maintaining oxygen delivery for the client’s needs.

Choice D reason: Decreasing the flow rate to 1 L/minute may worsen hypoxia, as 4 L/minute maintains 92% saturation. The lesion is due to tubing pressure, not flow rate. Padding addresses the skin issue without altering oxygen therapy, making flow reduction an ineffective and potentially harmful intervention for this scenario.

A. Compare the client’s health status with the defining criteria of related problems. B. Review the priority nursing problems included in the plan of care. C. List the nursing actions that need to be implemented most immediately. D. Ensure that all treatments prescribed by the healthcare provider have been initiated.

Correct Answer is B

Explanation

Choice A reason: Comparing health status with defining criteria helps diagnose problems but is less relevant when setting goals. Goal identification focuses on addressing established nursing problems to achieve measurable outcomes. This action is part of assessment, not the primary step in formulating care plan goals, which requires prioritizing existing issues.

Choice B reason: Reviewing priority nursing problems ensures goals align with the client’s most urgent needs. This step clarifies the focus of care, enabling the nurse to set specific, measurable, and patient-centered goals. It integrates assessment data and nursing diagnoses, forming the foundation for effective care planning, as per nursing process standards.

Choice C reason: Listing immediate nursing actions focuses on interventions, not goal-setting. Goals define desired outcomes, while actions are strategies to achieve them. This approach skips the critical step of establishing priorities and outcomes, risking a fragmented care plan that may not address the client’s holistic needs effectively.

Choice D reason: Ensuring all prescribed treatments are initiated addresses physician orders but not nursing-specific goals. Nursing goals focus on patient outcomes based on nursing diagnoses, not just medical treatments. This action is relevant to implementation, not the primary step in identifying care plan goals, which requires nursing judgment.

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An older adult woman with end-stage heart disease is hospitalized for severe heart failure (HF). She is alert, oriented, and requests that no heroic measures are implemented if her breathing stops. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes an open skin lesion across the right zygomatic bone of a client receiving oxygen per nasal cannula at 4 L/minute. The client’s oxygen saturation level is 92%. Which intervention should the nurse implement?

Correct Answer is B

Explanation

When identifying the goals to be included in a client’s plan of care, the nurse should take which action?

Correct Answer is B

Explanation

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