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 B

Explanation

A. Report any change in urine color is not a primary intervention in palliative care for this client. While monitoring urine output is important in assessing hydration status, it does not directly address the client's comfort, which is a key goal in palliative care.

B. Keep mucous membranes moist is a critical intervention for this client. Mouth breathing and the refusal of fluids can lead to dry mucous membranes, causing discomfort. Regular oral care using swabs or rinses can alleviate dryness, improving the client's comfort and quality of life.

C. Record the client's daily weight is unnecessary in this situation. Monitoring weight is typically relevant for clients whose fluid balance or nutritional status is being managed, which is not a focus in palliative care for a terminally ill client.

D. Maintain in high Fowler's position is not the priority in this scenario. While positioning may be adjusted to support breathing, the focus should remain on comfort, such as alleviating the dryness associated with mouth breathing.

A. Restrict oral fluid intake. B. Offer to warm the prune juice. C. Advance to a regular diet. D. Initiate bowel training protocol.

Correct Answer is D

Explanation

A. Restrict oral fluid intake is not appropriate in this situation. Decreased bowel sounds and constipation may indicate a need for hydration, not restriction of fluids. Fluids are essential to help prevent and alleviate constipation.

B. Offer to warm the prune juice may be helpful in some cases to encourage the client to drink, but it does not address the underlying issue of constipation and decreased bowel sounds. A more comprehensive intervention, such as bowel training, is needed.

C. Advance to a regular diet may not be appropriate without assessing the client's tolerance for additional food types. The client is on a mechanical soft diet, which may already be sufficient. Advancing to a regular diet could potentially exacerbate the constipation.

D. Initiate bowel training protocol is the most appropriate action. Bowel training is designed to help manage constipation and promote regular bowel movements. This may include dietary adjustments, increased fluid intake, and other measures such as scheduled toileting.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

A client on a mechanical soft diet is experiencing constipation and asks the nurse for a glass of prune juice. After auscultating decreased bowel sounds, which action should the nurse implement?

Correct Answer is D

Explanation

The nurse is caring for a client in isolation who requires wound care. The nurse should prepare to enter the room by performing these actions in which order? (Arrange with the first step on top and the last step at the bottom.)

In planning the turning schedule for a bedfast client, it is most important for the nurse to consider which assessment finding?

Which action should the nurse implement when inserting an indwelling catheter for an uncircumcised male client?

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?

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 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.)

Two clients ring their call lights simultaneously requesting pain medication. Which action should the nurse implement first?