The mother of two toddlers who was recently divorced is scheduled for breast augmentation. During the day surgery admission process, the client tells the nurse that she has not executed a living will, but does not want to be resuscitated or put on any mechanical breathing machines. Which action(s) should the nurse take? Select all that apply.

Notify the client's next of kin prior to surgery.

Encourage the client to execute a will that identifies a guardian for her children.

Flag the client's record with "do not resuscitate."

Document the client's statement on the admission form.

Explain the benefit of executing an advanced directive.

Answer and Explanation

Correct Answer : D,E

A. Notify the client's next of kin prior to surgery is not appropriate unless the client provides explicit consent. The nurse must respect the client's autonomy and confidentiality.

B. Encourage the client to execute a will that identifies a guardian for her children is outside the nurse's role. While the client’s family arrangements are important, this is not directly relevant to the surgical admission process.

C. Flag the client's record with "do not resuscitate" is not appropriate unless the client has completed the necessary documentation, such as an advance directive or physician orders for life-sustaining treatment (POLST).

D. Document the client's statement on the admission form is essential to ensure the healthcare team is aware of the client’s expressed wishes.

E. Explain the benefit of executing an advanced directive is appropriate because it informs the client about formalizing their wishes to avoid potential confusion during medical care.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

A. Elevate the head of the bed to a 45-degree angle may be helpful for some clients with OSA, but the most crucial intervention for a client with OSA is ensuring the proper use of the positive airway pressure (PAP) device.

B. Remove dentures or other oral appliance is not a priority for clients with OSA unless specifically contraindicated by the healthcare provider. The main concern is ensuring the PAP device is in place to prevent airway obstruction.

C. Lift and lock the side rails in place is a general safety measure, but it is not as critical as ensuring the client has their PAP device applied.

D. Apply the client's positive airway pressure device is the most important intervention. The PAP device (e.g., CPAP or BiPAP) helps keep the airway open during sleep, preventing apneas and improving oxygenation. Ensuring the client has this device in place is the most essential action before leaving the client alone.

A. Ensure the client's environment is properly cleaned and disinfected. B. Reapply sterile non-adhesive dressing. C. Initiate contact precautions. D. Teach family members how to prevent transmission of infection.

Correct Answer is C

Explanation

A. Ensure the client's environment is properly cleaned and disinfected is important, but the priority action is to prevent the spread of MRSA, which is highly contagious. Contact precautions should be initiated immediately to reduce the risk of transmission to others, including healthcare staff and visitors.

B. Reapply sterile non-adhesive dressing is necessary for wound care, but it is not the most important action in this scenario. Ensuring the appropriate precautions are taken to prevent the spread of MRSA is the priority.

C. Initiate contact precautions is the most important action. MRSA is a highly contagious bacterial infection that can spread easily through contact with contaminated surfaces or individuals. By initiating contact precautions, the nurse helps to protect other patients, staff, and visitors from exposure to MRSA.

D. Teach family members how to prevent transmission of infection is important but should be done after the immediate infection control measures, such as initiating contact precautions, have been implemented. Family education can occur once the proper isolation procedures are in place.

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Naxlex Comprehensive Predictor Exams

The nurse assists a client who has obstructive sleep apnea (OSA) with evening care. Which intervention is most important for the nurse to implement before leaving the client alone?

Correct Answer is D

Explanation

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Given there is a positive methicillin-resistant Staphylococcus aureus (MRSA) laboratory result, which action is the most important for the nurse to take?

Correct Answer is C

Explanation

The healthcare provider prescribes streptomycin 200 mg intramusculary every 12 hours. The vial is labeled, "Streptomycin 1 gram/2.5 mL". How many milliliters should the nurse administer? (Enter numerical value only. (If rounding is required, round to the nearest tenth.)

When assessing a client with a serum potassium level of 2.5 mEq/L (2.5 mmol/L), which intervention is most important for the nurse to implement?

The palliative care nurse receives a consult for a terminally ill client in the intensive care unit (ICU). The client is weak, mouth breathing, and refusing anything to eat or drink. Which intervention should the nurse include in the plan of care?

The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?

While teaching a client how to perform a skill, the nurse determines that the client is experiencing sensory overload and is unable to learn effectively. Which action should the nurse implement?

The nurse uses a sterile syringe to obtain a urine specimen from a client's indwelling urinary catheter. After placing the specimen in a biohazard bag, the nurse transports the specimen to the laboratory. During which part of this procedure should the nurse wear gloves?

The nurse is documenting wound care in a client's electronic medical record (EMR) when the computer system shuts down. Which action should the nurse implement first?

To assess the quality of an adult client's pain, which approach should the nurse use?