Which information should the practical nurse (PN) collect during the admission assessment of a terminally ill client to an acute care facility?

Health care proxy documentation.

Name of funeral home to contact

Client's wishes regarding organ donation

Contact information for the client's next of kin

Answer and Explanation

The Correct Answer is A

- A terminally ill client is a client who has a progressive and incurable disease or condition that is expected to result in death within a short period of time, such as months or weeks. A terminally ill client may require palliative care, which is the care that focuses on relieving pain and suﬀering and improving the quality of life for the client and their family.

- An admission assessment is the process of collecting information about a client's health status, needs, preferences, and goals when they are admited to a health care facility, such as a hospital, nursing home, or hospice. An admission assessment helps to establish a baseline for the client's condition, plan and implement appropriate interventions, and evaluate the outcomes of care.

- A health care proxy is a legal document that allows a client to appoint another person, such as a family member or a friend, to make health care decisions for them if they become unable to do so themselves. A health care proxy may also include specific instructions or preferences about the type and extent of care that the client wishes to receive or refuse, such as life-sustaining treatments, resuscitation, or organ donation.

- Health care proxy documentation is an important information that the practical nurse (PN) should collect during the admission assessment of a terminally ill client to an acute care facility, as it reﬂects the client's autonomy, dignity, and wishes regarding their end-of-life care. It also helps to ensure that the client's healthcare decisions are respected and followed by the healthcare team and the facility.

- Therefore, option A is the correct answer, while options B, C, and D are incorrect.

Option B is incorrect because the name of the funeral home to contact is not relevant or necessary for the admission assessment of a terminally ill client, as it does not aﬀect their health status or care plan.

Option C is incorrect because the client's wishes regarding organ donation may be included in their health care proxy documentation, but they are not required or essential for the admission assessment of a terminally ill client.

Option D is incorrect because the contact information for the client's next of kin may be useful for communication and support purposes, but it is not as important as the health care proxy documentation for the admission assessment of a terminally ill client.

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Correct Answer is B

Explanation

Choice A rationale:

Objective data. Rationale: Objective data are observable and measurable facts obtained through physical examination or diagnostic tests. The statement incorrectly labels the data as objective when it is, in fact, based on the client's feelings and perceptions, making it subjective.

Choice B rationale:

Subjective data. Rationale: Subjective data are information provided by the client, including their feelings, perceptions, and experiences. The statement correctly labels the data as subjective, as it reflects the client's report of thirst and hunger.

Choice C rationale:

Primary data. Rationale: Primary data are original data collected directly from the source, such as a client's medical history or interview. However, this classification does not address the nature of the data as being subjective or objective, so the statement does not provide a complete answer.

Choice D rationale:

Secondary data. Rationale: Secondary data are data obtained from sources other than the client, such as medical records or research studies. Similar to choice C, this classification does not address the nature of the data as being subjective or objective.

A. Administer a PRN dose of acetaminophen. B. Encourage the client to drink ﬂuids. C. Report the findings to the charge nurse. D. Monitor the client's serum lipid levels.

Correct Answer is C

Explanation

This is the priority action by the practical nurse (PN) because it can help identify and prevent a potential adverse reaction to the medication. A client who is reaching saturation with medication means that the client has reached the maximum level of medication in the blood that can produce the desired therapeutic eﬀect. However, this also means that the client is at a higher risk of developing toxicity or side eﬀects from the medication. The PN should report the findings of muscle soreness, fatigue, and warm skin to the charge nurse, as these may indicate signs of inﬂammation, infection, or allergic reaction to the medication. The PN should also monitor the client's vital signs, oxygen saturation, and laboratory values, and document the findings. The charge nurse should notify the health care provider and adjust the medication dosage or regimen as ordered.

a) Administer a PRN dose of acetaminophen.

This is not the priority action by the PN because it does not address the underlying cause of the client's symptoms. Acetaminophen is an analgesic and antipyretic medication that can help reduce pain and fever. However, it does not treat inﬂammation, infection, or allergy, which may be the reasons for the client's muscle soreness, fatigue, and warm skin. The PN should administer a PRN dose of acetaminophen only after reporting the findings to the charge nurse and obtaining an order from the health care provider.

b) Encourage the client to drink ﬂuids.

This is not the priority action by the PN because it does not address the underlying cause of the client's symptoms. Drinking ﬂuids can help maintain hydration and electrolyte balance in the body, which are important for normal functioning of cells and organs. However, it does not treat inﬂammation, infection, or allergy, which may be the reasons for the client's muscle soreness, fatigue, and warm skin. The PN should encourage the client to drink ﬂuids only after reporting the findings to the charge nurse and obtaining an order from the health care provider.

d) Monitor the client's serum lipid levels.

This is not the priority action by the PN because it is not related to the client's symptoms. Serum lipid levels are measures of fats and cholesterol in the blood, which are important for energy production, hormone synthesis, and cell membrane structure. However, they are not related to inﬂammation, infection, or allergy, which may be the reasons for the client's muscle soreness, fatigue, and warm skin. The PN should monitor the client's serum lipid levels only if they are prescribed a medication that can aﬀect lipid metabolism, such as statins or fibrates.

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Which information should the practical nurse (PN) collect during the admission assessment of a terminally ill client to an acute care facility?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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