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 C

Explanation

A. Withhold the medication until the exact dose is available is not the best first action. The nurse should first report the discrepancy to ensure that the prescribed dose is correct and to confirm if the medication should be withheld or adjusted.

B. Calculate the dose on hand to match the prescribed dose is not appropriate. The nurse should not attempt to adjust the medication dose without confirmation from the healthcare provider or pharmacist.

C. Report a mismatch of prescribed and available doses is the correct action. The nurse should immediately report the discrepancy to the pharmacist or healthcare provider to verify the correct dose and prevent potential harm to the client.

D. Ask the pharmacist if another dose can be dispensed is an appropriate follow-up action but is secondary to reporting the mismatch first. The nurse needs to clarify the prescription and dosage before taking further steps.

A. Capillary refill time is 2 seconds. B. 2+ edema of fingers and hands. C. Blood pressure is 142/88 mm Hg. D. Radial pulse volume is 3+.

Correct Answer is B

Explanation

A. Capillary refill time is 2 seconds is within the normal range and is unlikely to interfere with the pulse oximeter reading.

B. 2+ edema of fingers and hands most likely contributes to the low oxygen saturation reading. Edema can impair the accuracy of a pulse oximeter by affecting the transmission of light through the tissues, leading to erroneous readings.

C. Blood pressure is 142/88 mm Hg is mildly elevated but does not directly affect the pulse oximeter's ability to measure oxygen saturation.

D. Radial pulse volume is 3+ indicates a strong pulse and does not interfere with the functionality of the pulse oximeter.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The electronic medication system alerts the nurse that the medication dose scanned for the client is two times higher than the dose prescribed. Which action should the nurse implement?

Correct Answer is C

Explanation

The nurse attaches a pulse oximeter to a client's finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

Correct Answer is B

Explanation

The nurse is administering an intradermal (ID) injection to a client. Which action should the nurse take?

A client's spouse has just learned of the client's terminal illness. The spouse is sitting in the corner of the client's room crying, and says to the nurse, "I feel as if I'm already so alone." Which action should the nurse take first?

When administering a new medication to a client, the nurse logs in the electronic medication administration record (eMAR). Which action should the nurse take next?

The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action indicates that a UAP understands gloving procedures?

A confused older adult client is having trouble sleeping at night and is sometimes found wandering in the hallway. Which nursing intervention should the nurse implement first?

The healthcare provider prescribes digoxin elixir 125 mcg PO daily. The drug is available in a 60 mL bottle labeled, "Digoxin elixir 0.05 mg/mL How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

Which assessment data reflects the need for the nurse to include the problem, "Risk for falls," in a client's plan of care? Reference Range: Hemoglobin [14 to 18 g/dL (140 to 180 g/L)]

A surgical incision that is healing by secondary intention develops a thick tan exudate. Which action should the nurse take first?