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. Self-care deficit might apply if the client is unable to perform foot care independently. However, the priority concern is addressing the potential complications of neuropathy, such as skin breakdown, before considering assistance with care.

B. Risk for infection is a valid concern, especially if skin integrity is compromised. However, infection prevention depends on maintaining intact skin, making skin integrity the more immediate priority.

C. Impaired physical mobility may contribute to challenges in foot care but does not directly address the risk posed by neuropathy, which primarily affects sensory perception and increases vulnerability to unnoticed injuries.

D. Risk for impaired skin integrity is the priority because neuropathy reduces sensation in the feet, increasing the likelihood of unnoticed injuries, pressure sores, or burns. Early identification and prevention of skin damage are essential for avoiding complications.

A. Withhold the medication until the exact dose is available. B. Calculate the dose on hand to match the prescribed dose. C. Report a mismatch of prescribed and available doses. D. Ask the pharmacist if another dose can be dispensed.

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.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

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 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.)

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

A client is being discharged postsurgery. Which information provided by the client requires additional instruction by the nurse?

While measuring vital signs, the nurse observes that a client is using accessory neck muscles during respirations. Which follow-up action should the nurse take first?

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?

When initiating oxygen per mask to a client who is short of breath, the nurse hears a loud hissing sound after inserting the flowmeter into the wall outlet. Which should the nurse do next?

The nurse observes a newly employed unlicensed assistive personnel (UAP) checking the temperature of an adult client using a tympanic thermometer. The UAP pulls the client's auricle up and back and prepares to insert the thermometer. Which action should the nurse implement?

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