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. Whether they contain pulp or fruit is unnecessary to assess because flavored gelatin is typically free of pulp or fruit. The concern lies more with the appropriateness of the ingredients as clear liquids.

B. The color and flavor of gelatin used is the correct response because some colored gelatins (e.g., red or purple) can mimic blood if vomiting occurs, potentially leading to misinterpretation of the child’s condition. The nurse should ensure that the parent uses neutral or light-colored gelatin (e.g., yellow or clear).

C. How many popsicles are available is not relevant to the appropriateness of the popsicles as a clear liquid or their potential effects on the child’s condition.

D. If the popsicles are completely frozen is not significant as long as the popsicles are made from appropriate clear liquids.

A. "Wash your hands after each administration of eye drops." B. "Squeeze your eye closed after administering the drops." C. "Do not allow the dropper bottle to touch the eye." D. "Administer the medication directly on the cornea."

Correct Answer is C

Explanation

A. "Wash your hands after each administration of eye drops" is important but not specific to the safe administration of miotic eye drops. Washing hands before administration is more relevant to preventing infection.

B. "Squeeze your eye closed after administering the drops" can force the medication out of the eye, reducing its effectiveness. Instead, the client should be instructed to close the eye gently and apply pressure to the inner canthus to prevent systemic absorption.

C. "Do not allow the dropper bottle to touch the eye" is correct because it prevents contamination of the dropper, which could lead to eye infections.

D. "Administer the medication directly on the cornea" is incorrect because eye drops should be placed in the conjunctival sac, not directly on the cornea, to minimize irritation and maximize absorption.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

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?

Correct Answer is C

Explanation

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

The nurse educators on a cardiovascular unit of a health care facility are creating a social media project that addresses improving outcomes for clients with heart failure. Which action should the nurses implement to protect client privacy?

A client with a sprained ankle is seen at the clinic and is given a pair of crutches. When the client stands with the aid of the crutches, the nurse notes a space of three finger-widths between the top of the crutch and the client's axilla. Which action should the nurse take?

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.)

A client with atrial fibrillation receives a prescription for a loading dose of digoxin 0.5 mg PO. The medication is available in 125 mcg tablets. How many tablets should the nurse administer? (Enter numerical value only.)

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?

The nurse is caring for a client who is overweight and easily becomes diaphoretic. In response to this finding, which assessment(s) should the nurse include while assisting the client with personal care? Select all that apply.