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.

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Correct Answer is D

Explanation

A. Recent serum hemoglobin level of 16 g/dL (160 g/L) is within the normal range and does not indicate an increased risk for falls.

B. Expressed feelings of depression may affect motivation or activity levels but does not directly increase the risk of falls unless it leads to physical symptoms such as fatigue or unsteady gait.

C. Stooped posture with a steady gait might suggest a musculoskeletal issue, but the "steady gait" does not indicate immediate fall risk.

D. Opioid analgesic received one hour ago is the most relevant factor because opioids can cause dizziness, sedation, and impaired coordination, all of which increase the likelihood of falls. The timing of the medication further highlights the need for vigilance.

A. Obtain the specimen from the client's current bowel movement. B. Withhold specimen collection until tarry black stool is observed. C. Contact the healthcare provider before obtaining the specimen. D. Wait to obtain the specimen until observable blood is present.

Correct Answer is A

Explanation

A. Obtain the specimen from the client's current bowel movement is the correct action. Occult blood can be present even in normal-appearing stool. The nurse should obtain the specimen from the current bowel movement, as it is part of the protocol for testing for hidden blood in the stool. The stool does not need to be tarry or black to test for occult blood.

B. Withhold specimen collection until tarry black stool is observed is incorrect. Tarry black stools often indicate the presence of digested blood, but occult blood testing is designed to detect blood that may not be visible to the naked eye, even in normal-colored stool.

C. Contact the healthcare provider before obtaining the specimen is unnecessary. The nurse can proceed with the collection as per the standard procedure without needing to contact the healthcare provider, unless there is a specific reason to do so.

D. Wait to obtain the specimen until observable blood is present is incorrect. The purpose of an occult blood test is to detect hidden (occult) blood, which may not be visible to the eye. The nurse should not wait for visible blood to appear before collecting the specimen.

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Naxlex Comprehensive Predictor Exams

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)]

Correct Answer is D

Explanation

While preparing to obtain a stool specimen for occult blood, the nurse observes that the client's feces is soft, solid, and light brown. Which action should the nurse implement?

Correct Answer is A

Explanation

A client diagnosed with primary open-angle glaucoma received a prescription for miotic eye drops. Which instruction should the nurse plan to include in this client's teaching?

A client who had emergency gallbladder surgery yesterday is getting ready for discharge. The client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client's understanding of self-care at home?

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?

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?

A child has experienced several episodes of vomiting. After the nurse reviews the need to provide only clear liquids, the parent of the child reports making clear liquid popsicles out of flavored gelatin for the child. Which information should the nurse obtain about the popsicles?

The nurse is conducting an initial admission assessment for a woman who is a Jehovah's Witness and is scheduled to deliver a baby by Cesarean section within the next 24 hours. Which action should the nurse take?

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

A 19-year-old client is admitted to the hospital with severe right lower quadrant abdominal pain. The father is requesting to know his son's laboratory test results. Which is the best response for the nurse to provide?