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NurseDive Free Nursing Practice Question
A nurse is assisting with the care of a client.
Laboratory Results
Abdominal ultrasound: mass present in small intestine proximal to ileocecal valve. Size of mass is 6 cm x 7 cm (2.4 in x 2.8 in).
Select the 4 responsibilities the nurse has in relation to the client's advance directives.
A. Inform the client that an advance directive discontinues further care.
An advance directive does not automatically discontinue further care. It simply provides guidance to healthcare providers on the client's wishes for medical treatment. It is important for the nurse to explain this to the client and ensure that they understand the purpose of an advance directive.
B. Initiate a power of atorney for health care document.
While nurses can provide information and support the client in understanding the importance of having a power of attorney for healthcare, initiating such documents is typically not within the scope of nursing practice. This task usually requires legal guidance and formalities that go beyond nursing responsibilities.
C. Document that the provider discussed do-not-resuscitate status with the client.
Accurate documentation is crucial in healthcare. If a provider discusses do-not-resuscitate (DNR) status with a client, it must be documented in the client's medical record to ensure that all healthcare team members are aware of the client’s wishes.
D. Provide the client with written information about advance directives.
It is important for the nurse to provide the client with writen information about advance directives, including their rights and options for creating an advance directive. This information should be provided in a clear and understandable manner.
E. Communicate advance directives status via the medical record and shift report.
The nurse should communicate the client's advance directives status to other members of the healthcare team via the medical record and shift report. This ensures that everyone involved in the client's care is aware of the client's wishes and can provide care that is consistent with those wishes.
F. Instruct the client that an advance directive is a legal document and must be honored by care providers.
The nurse should instruct the client that an advance directive is a legal document that must be honored by care providers. This ensures that the client understands the importance of their advance directive and can advocate for their wishes if necessary.
This question is an excerpt from Nurse Dive's nursing test bank - PN Comprehensive Predictor PN 2020 Proctored Exam. Take the full exam now
Full Explanation
c, d, e, and f.
a. An advance directive does not automatically discontinue further care. It simply provides guidance to healthcare providers on the client's wishes for medical treatment. It is important for the nurse to explain this to the client and ensure that they understand the purpose of an advance directive.
b. While nurses can provide information and support the client in understanding the importance of having a power of attorney for healthcare, initiating such documents is typically not within the scope of nursing practice. This task usually requires legal guidance and formalities that go beyond nursing responsibilities.
c. Accurate documentation is crucial in healthcare. If a provider discusses do-not-resuscitate (DNR) status with a client, it must be documented in the client's medical record to ensure that all healthcare team members are aware of the client’s wishes.
d. Provide the client with writen information about advance directives: It is important for the nurse to provide the client with writen information about advance directives, including their rights and options for creating an advance directive. This information should be provided in a clear and understandable manner.
e. Communicate advance directives status via the medical record and shift report: The nurse should communicate the client's advance directives status to other members of the healthcare team via the medical record and shift report. This ensures that everyone involved in the client's care is aware of the client's wishes and can provide care that is consistent with those wishes.
f. Instruct the client that an advance directive is a legal document and must be honored by care providers: The nurse should instruct the client that an advance directive is a legal document that must be honored by care providers. This ensures that the client understands the importance of their advance directive and can advocate for their wishes if necessary.
Similar Questions
A nurse is assisting with the care of a client in a medical-surgical unit.
Vital Signs
05:00
Temperature 36.6 C (97.9 F)
Heart rate 100/min
Respiratory rate 22/min
Blood pressure 160/98 mm Hg
Oxygen saturation 96% on oxygen 2 L/min via nasal cannula
14:00
Temperature 36.8 C (98.3 F)
Heart rate 90/min
Respiratory rate 18/min
Blood pressure 138/88 mm Hg
Oxygen saturation 97% on oxygen 2 L/min via nasal cannula
Which of the following actions should the nurse take to decrease the risks for a urinary tract infection for this client? Select all that apply.
A. Encourage the client to drink 3,000 mL of fluid daily.
To decrease the risks for a urinary tract infection for this client, the nurse should take several actions. The nurse should encourage the client to drink 3,000 mL of fluid daily to help flush bacteria out of the urinary tract¹.
B. Change the indwelling urinary catheter tubing every 3 days.
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C. Place the drainage bag on the bed when transporting the client.
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D. Empty the drainage bag when it is half-full.
The nurse should also empty the drainage bag when it is half-full to prevent bacterial growth¹.
E. Review the need for the indwelling urinary catheter daily.
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F. Use soap and water to provide perineal care.
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Full Explanation
To decrease the risks for a urinary tract infection for this client, the nurse should take several actions. The nurse should encourage the client to drink 3,000 mL of fluid daily to help flush bacteria out of the urinary tract¹. The nurse should also empty the drainage bag when it is half-full to prevent bacterial growth¹.
Additionally, the nurse should review the need for the indwelling urinary catheter daily and use soap and water to provide perineal care¹.
The nurse is identifying tertiary prevention strategies to implement for this client.
Select the three actions the nurse should take.
A. Insist that the client explain the reason for their bruises.
None
B. Inform the client that their child is being abusive toward them.
None
C. Report suspected maltreatment to the appropriate agency.
None
D. Confront the client's child about the client's injuries.
None
E. Ask the client how the fracture occurred.
None
F. Conduct the interview with the client privately.
None
Full Explanation
In a situation where maltreatment is suspected, it is important for the nurse to report their concerns to the appropriate agency. The nurse should also ask the client how the fracture occurred and conduct the interview with the client privately, without the presence of their child, to gather more information and assess the situation.
A nurse in a provider's office is reinforcing teaching about skin care with a client who has a new diagnosis of systemic lupus erythematosus. Which of the following statements by the client indicates an understanding of the teaching?
A. "I will limit my time in the tanning bed to 15 minutes."
B. "I will dry my skin by patting it with a towel."
People with SLE are often sensitive to sunlight and should take precautions to protect their skin. Limiting time in the tanning bed is important because exposure to ultraviolet (UV) light can trigger or worsen symptoms of SLE. Using an astringent on the face and cleansing with an antibacterial soap may not be recommended for individuals with SLE, as these products can be harsh on the skin and may cause irritation. However, patting the skin dry with a towel is a gentle and appropriate method to dry the skin without causing unnecessary friction or irritation.
C. "I will use an astringent on my face."
D. "I will cleanse my skin using an antibacterial soap."
Full Explanation
People with SLE are often sensitive to sunlight and should take precautions to protect their skin. Limiting time in the tanning bed is important because exposure to ultraviolet (UV) light can trigger or worsen symptoms of SLE. Using an astringent on the face and cleansing with an antibacterial soap may not be recommended for individuals with SLE, as these products can be harsh on the skin and may cause irritation. However, patting the skin dry with a towel is a gentle and appropriate method to dry the skin without causing unnecessary friction or irritation.