Struggling to breathe, an older adult client with end-stage chronic obstructive pulmonary disease (COPD) is admitted through the emergency department. The client is anxious and considering mechanical ventilation when the spouse interrupts the nurse and hands the nurse a copy of the client’s living will. Which action is most important for the nurse to take?

Facilitate a family meeting with the palliative care team.

Alert the nursing staff of the client’s do not resuscitate wishes.

Place a certified copy of the living will in the client’s electronic health record (EHR).

Notify the healthcare provider of the client’s wishes.

Answer and Explanation

The Correct Answer is D

Choice A reason: Facilitating a family meeting with palliative care discusses end-of-life goals in COPD, where airway obstruction causes respiratory failure. However, notifying the provider of the living will ensures immediate alignment with the client’s wishes, especially on ventilation, addressing the urgent need to respect legal directives in a critical scenario.

Choice B reason: Alerting staff about do-not-resuscitate (DNR) wishes assumes the living will specifies DNR, which requires confirmation. The provider must review the document first, as end-stage COPD necessitates clarity on ventilation preferences to guide urgent care, making notification the priority over premature staff alerts.

Choice C reason: Placing the living will in the EHR ensures documentation but does not immediately affect care. In end-stage COPD with respiratory distress, notifying the provider ensures the client’s wishes, like avoiding intubation, are followed promptly, preventing unwanted interventions, making this more urgent than administrative tasks.

Choice D reason: Notifying the provider of the living will is critical, as it legally specifies the client’s preferences, potentially refusing ventilation in end-stage COPD, where dyspnea results from irreversible obstruction. This ensures treatment respects autonomy, guiding immediate care to align with palliative goals, preventing inappropriate interventions during a crisis.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Choice A reason: Memory issues from TBI traumatic brain injury warrant cognitive assessment, not CAGE, which screens for alcoholism. Daily drinking suggests potential misuse, requiring CAGE. Memory affects recall, not alcohol screening priority, per substance abuse and neurological assessment standards in nursing admission interviews.

Choice B reason: Daily social drinking raises suspicion for alcohol misuse, warranting the CAGE questionnaire to screen for dependence. CAGE assesses alcohol-related behaviors, critical for identifying alcoholism in clients with regular intake, per substance abuse screening and admission assessment protocols in nursing practice.

Choice C reason: Antidepressant medication use suggests depression, requiring mental health assessment, not CAGE, which is for alcohol misuse. Daily drinking indicates screening need. Antidepressants are unrelated to alcohol patterns, per psychiatric and substance abuse assessment standards in nursing care during admission.

Choice D reason: Sexual assault history trauma requires trauma-informed care, not CAGE, which screens for alcoholism. Daily drinking triggers alcohol misuse screening. Assault history addresses psychological needs, per trauma assessment and substance abuse screening protocols, but CAGE is specific to alcohol in nursing.

A. “Your PCA pump has just been discontinued, and you need to wait at least one hour before leaving the unit.” B. “As long as you go to the smoking area in a wheelchair, it will be all right for you to go smoke.” C. “You may smoke in your room if you keep the door closed and open a window.” D. “Smoking is hazardous to your health, and since you just had surgery, it would be best for you to avoid smoking.”

Correct Answer is D

Explanation

Choice A reason: Delaying smoking for one hour is arbitrary and does not address smoking’s risks post-surgery. Nicotine causes vasoconstriction, reducing wound perfusion, and carbon monoxide impairs oxygen delivery, delaying healing. Advising against smoking mitigates these risks, promoting recovery, making this response less effective than cessation advice.

Choice B reason: Allowing smoking in a wheelchair ignores postoperative risks. Nicotine’s vasoconstriction reduces tissue oxygenation, and carbon monoxide lowers hemoglobin’s capacity, impairing healing. This increases infection or thrombosis risk. Advising against smoking addresses these physiological harms, prioritizing wound recovery over facilitating smoking, which is detrimental.

Choice C reason: Smoking in the room violates hospital safety and exposes others to secondhand smoke. Nicotine and carbon monoxide reduce tissue perfusion and oxygen delivery, delaying postoperative healing. Advising against smoking prevents these complications, ensuring better recovery, making this response unsafe and inappropriate for surgical patients.

Choice D reason: Advising against smoking is critical, as nicotine causes vasoconstriction, reducing blood flow to surgical sites, and carbon monoxide impairs oxygen delivery, delaying healing. These increase infection and thrombosis risks post-surgery. This response promotes optimal recovery, addressing physiological needs for wound healing in the critical 24-hour period.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which client information indicates the need for the nurse to use the CAGE questionnaire during the admission interview?

Correct Answer is B

Explanation

When the nurse discontinues a 24-hour postoperative client’s patient-controlled analgesia (PCA) pump, the client asks to go to the hospital’s smoking area to smoke a cigarette. Which response should the nurse provide?

Correct Answer is D

Explanation

The nurse is reviewing the recommended preventative care for clients with asthma, chronic bronchitis, and emphysema. Which health care measure is most important for the nurse to recommend to these clients?

A client who had a radical neck dissection returns to the surgical unit with two surgical drains in the right side of the incision. One drain bulb is open and has minimal drainage. Which action should the nurse take to increase drainage into the drain?

The nurse measures the client’s blood pressure (BP) and notes that it is significantly higher than the previous reading. Which should the nurse do next? (Select all that apply)

On the second postoperative day, a client reports increasing abdominal pain. Assessment findings include a distended abdomen with absent bowel sounds. Which intervention should the nurse anticipate implementing?

A client has begun a long-term maintenance therapy with lithium, which has a narrow therapeutic index. Which adverse effect is most important for the nurse to include in the teaching plan?

Prior to initiating digital removal of a fecal impaction, it is most important for the nurse to perform which client assessment?

Following admission for a cardiac catheterization, the nurse is providing discharge teaching to the parents of a 2-year-old toddler with Tetralogy of Fallot. Which instruction should the nurse give the parents if their child becomes pale, cool, and lethargic?

Which serum laboratory test is most important for the nurse to monitor when administering enoxaparin to a client?