The nurse has reviewed the Nurses' Notes and Provider Prescriptions at 1100 and Diagnostic Results on Day 3.

The nurse is preparing the client for surgery. Which of the following actions should the nurse take? Select all that apply.

Advance directives and health care proxy designations are legal tools that allow clients to communicate their preferences for medical care in the event they become unable to make decisions. A health care proxy, or durable power of attorney for health care, allows a client to appoint a trusted individual to make health decisions on their behalf. This person does not have to be a family member and should be someone who understands the client’s values and wishes. Understanding these legal rights ensures autonomy and appropriate surrogate decision-making.

Rationale:
A. Having a health care proxy does not eliminate the need for a living will because both documents serve different purposes. A living will outlines specific treatment preferences, while a health care proxy designates a decision-maker. Clients are often encouraged to have both to ensure comprehensive advance care planning in situations such as Advance directive.

B. Assigning a health care proxy does not mean the client loses the right to make their own decisions while they are still competent. The proxy only becomes active when the client is unable to communicate or make informed decisions. Until that time, the client retains full autonomy over their health care choices.

C. A health care proxy does not need to be a relative; it can be any trusted individual chosen by the client. The key requirement is that the designee understands and can advocate for the client’s wishes. This statement demonstrates correct understanding of the flexibility in selecting a surrogate decision-maker.

D. A health care proxy designee is authorized to make decisions and can sign consent forms when the client is unable to do so. This includes consenting to or refusing treatments based on the client’s wishes or best interests. Therefore, this statement reflects a misunderstanding of the proxy’s legal authority.

Assessment of a reproductive-age client with delayed menses, abdominal pain, and vaginal spotting requires urgent evaluation for possible early pregnancy complications such as Ectopic pregnancy or threatened pregnancy loss. The combination of abnormal uterine bleeding, missed menstrual period, and localized abdominal tenderness can indicate an early obstetric emergency before hemodynamic instability develops. Nurses must prioritize findings that suggest potential pregnancy-related pathology rather than stable vital signs or unrelated systems.

Rationale:
A. A temperature of 37.3°C (99.1°F) is within normal limits and does not suggest infection or acute systemic compromise. There are no accompanying signs of sepsis or inflammatory process such as chills, leukocytosis, or worsening vital instability. This finding does not require immediate follow-up in the current clinical context.

B. Vaginal spotting requires immediate follow-up because it may represent abnormal implantation, threatened abortion, or early ectopic pregnancy bleeding. In a client with delayed menses and abdominal pain, even scant dark red bleeding becomes highly significant. This can be an early sign of trophoblastic disruption or tubal irritation, requiring urgent evaluation to rule out pregnancy complications.

C. The menstrual history showing a 2-week delayed period with last menses 6 weeks ago is a critical finding requiring follow-up because it raises suspicion of early pregnancy. When combined with abdominal pain and spotting, it becomes highly suggestive of possible ectopic pregnancy or early pregnancy complication. Establishing gestational status is essential for determining urgency of further diagnostic testing.

D. Hyperactive bowel sounds alone are not specific for obstetric emergencies and may be influenced by anxiety, diet, or mild gastrointestinal activity. Although abdominal conditions can sometimes coexist, bowel sounds are not the primary indicator of early pregnancy complications. Therefore, this finding is less urgent compared to bleeding and menstrual changes.

E. A heart rate of 90/min is within normal limits and does not indicate hemodynamic instability. There are no signs of shock such as tachycardia, hypotension, or altered mental status. This finding does not require immediate intervention in this context.

F. Slight inspiratory wheezes are consistent with the client’s known asthma history and are not currently causing respiratory compromise. Oxygenation is stable, and there is no acute respiratory distress. This finding is not a priority compared to reproductive system concerns.

G. Oxygen saturation of 97% on room air is normal and indicates adequate oxygenation. There is no evidence of respiratory dysfunction requiring intervention. This value is stable and not clinically urgent.

H. Abdominal tenderness, particularly in the right lower quadrant, requires immediate follow-up because it may indicate implantation in the fallopian tube or irritation from ectopic pregnancy. When combined with delayed menses and vaginal spotting, it becomes highly concerning for a potentially life-threatening condition. Early identification is critical to prevent rupture and internal hemorrhage.