The client suffered cardiac arrest, was resuscitated and has now been on a ventilator for several days.
The client had a written advance directive which the spouse brought from home.
The primary care provider (PCP) is encouraging the spouse to consent for placement of a percutaneous endoscopic gastrostomy (PEG) tube, which is contrary to the client's advance directive.
After the PCP leaves, the spouse states, "I wish I knew what my spouse wanted.”. What is the best reply by the nurse?

Choice A rationale

Creating a plan of care for a client recovering from a stroke requires comprehensive assessment, synthesis of complex data, and the establishment of nursing diagnoses and interventions. This falls within the scope of practice of a registered nurse who has the education and expertise in complex patient management.

Choice B rationale

Assessing a pressure injury involves observing and documenting wound characteristics. While an RN may perform this, an LVN, under the supervision of an RN, can also contribute to this task by collecting and reporting data about the wound.

Choice C rationale

Providing oral suctioning is a basic nursing skill that can be performed by both RNs and LVNs, following appropriate training and established protocols, to maintain airway patency for a client with pneumonia.

Choice D rationale

Administering internal feedings through a nasogastric tube is a task that can be delegated to an LVN who has received specific training and demonstrated competency, under the supervision of an RN, provided the client is stable and the feeding protocol is well-established.

Choice E rationale

Inserting a urinary catheter can be performed by both RNs and LVNs who have received the necessary education, training, and demonstrated competency in this invasive procedure, according to facility policies and state regulations.

Choice A rationale

Refusing to administer the medication without further investigation could jeopardize the client's timely treatment. While safety is paramount, the nurse's initial action should be to gather more information rather than outright refusal, which could delay necessary care.

Choice B rationale

Administering a medication that appears to be abnormally high without verifying the order is unsafe and could lead to serious adverse effects for the client. Nurses have a professional responsibility to question orders that seem incorrect or potentially harmful.

Choice C rationale

Documenting concerns is an important step in the process, but it is not the best *next* action. While documentation is crucial for legal and communication purposes, directly addressing the potentially erroneous order with the prescriber takes precedence to ensure patient safety.

Choice D rationale

Querying the physician about the order is the most appropriate immediate action. This allows the nurse to clarify the dosage, route, and rationale for the high dose. It opens a dialogue with the prescriber to confirm the order's accuracy or identify a potential error, directly addressing the safety concern.