Hurst NCLEX RN Review - Safe and effective care

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• a client informs the nurse during the hospital admission

assessment that the client does not have an advance directive, but designates the daughter to make Healthcare decisions in the event that the client becomes incapacitated or unable to make informed decisions.Which nursing actions are appropriate for this client?Select all that apply.

• Document the client's statement in the client's own words.
• Provide information on advance directives to the client.
• Inform the client that Personnel are available to assist with completing an

advance directive if the client wishes to do so.

• The nurse inquiring about the client advance directive could cause the client

anxiety and concern and should be avoided.Answer- a, b, and c The nurse should document the client's statement in the client's own words. The nurse should provide the client with information on advance directives and reassurance that there are Hospital Personnel to assist of completing the advance directive. the nurse should explain to the client that the law requires all kinds to be asked about the existence of an advance directive at the time of hospital admission. Preparing an advance directive ensures that the client's wishes will be followed.A.

• durable power of attorney for Health Care is an

example of... SATA

• An advance directive.
• A legal document that identifies a surrogate decision-maker for the client's

financial matters in the event that the client becomes incapacitated.

• A legal document that identifies a surrogate decision-maker in the event the

client becomes incapacitated or unable to make informed decisions.

• A legal document that becomes a permanent part of the client's medical

record.Answer - a, c, d. Healthcare durable power of attorney is an example of an advance directive. Advance directives are documents signed by a competent person giving direction to healthcare providers about treatment choices. A durable power of attorney for Health Care is a legal document that identifies a surrogate decision-maker for Health Care decisions. The document becomes a permanent part of the client's medical record. A legal document that identifies a client surrogate for financial matters is incorrect because a durable power of attorney for Health Care identifies the decision maker for Health Care decisions only, this document does not designate a surrogate for financial matters.

• a client with a do not resuscitate - do not intubate

order in the medical record becomes unresponsive and a code blue is called. The code team arrives and the physician is preparing to intubate the client. What action should the nurse take regarding the DNR - DNI order?

• Prepare the client for immediate intubation. Assist the physician with the

intubation procedure as needed.

• Immediately inform the physician and code team of the clients DNR order in the

medical record.

• Assist the code team with the code blooper Advanced Care life support

Protocol.

• Notify the physician in code team of the clients DNR order in the medical

record, but the physician responding to the code blue will make the decision whether or not to intubate the client.Answer - B. It's the nurses responsibility to know the clients code status and the treatment wishes of the client when a DNR order is in effect. The nurse must communicate this information to other healthcare providers. Providing treatment to a client who desires no treatment is considered battery.

• a disoriented client is admitted to the med-surg unit

with a diagnosis of acute renal failure. The Physician orders a hemodialysis lying to be placed to facilitate acute hemodialysis. The client's spouse presents the nurse with an advance directive that gives instructions that no hemodialysis treatment be provided if the client becomes incapacitated and unable to make informed Healthcare decisions. What is the appropriate immediate action for the nurse to take at this time?

• Inform the physician immediately of the advance directive and the client's

wishes regarding no hemodialysis treatment. Place a copy of the advance directive in the client's medical record.

• Obtain consent from the client spouse for placement of a hemodialysis line.
• Inform the physician immediately of the advance directive in the client's wishes

regarding no hemodialysis treatment.

• Tell the client spouse to speak with a physician in order to make an informed

decision on whether or not to proceed with hemodialysis.Answer - a. The Physician should be informed immediately if orders conflict with the client's wishes. A copy of the advance directive should always be placed in the client's medical record. obtaining orders against the client's wishes is considered battery.

• a client presents a durable power of attorney for

Health Care designating the client's nice as the person to make Healthcare decisions for the client should the client become incapacitated and unable to make informed Healthcare decisions. The durable power of attorney identifies the nice as the...

• Legal next of kin.
• Health Care proxy or surrogate decision-maker for Health Care issues only.
• Health Care proxy or surrogate decision-maker for healthcare and financial

Issues.

• Person responsible for the clients hospital bill.

Answer - B. A durable power of attorney for Health Care is an advance directive prepared by a competent individual designating a proxy or surrogate decision- maker should the client become incapacitated.

• a nurse is taking a client's medical history in the

emergency room. The nurse asks if the client has an advance directive. The client responds by saying I have heard of advance directives but I do not have one. What is an advance directive? What is the nurses best response to the clients question?

• An advance directive is a document that specifies your wishes regarding your

personal effects and finances should you become an able to make the decisions.

• An advance directive is a document that specifies your wishes regarding

healthcare and your finances should you become incapacitated.

• An advance directive is a document similar to a will, and specifies your wishes

for burial should you die during hospitalization.

• An advance directive is a form of a living will. It specifies your wishes regarding

health care and treatment options should you become incapacitated.Answer - advance directive is a legal document prepared by a competent individual that specifies What treatments the client desires should the client become incapacitated or unable to make a decision. it does not address the client's personal effects, finances, or burial wishes. These would be included in the last will and testament.

• Which documents are correctly identified as advance

directives? Select all that apply.

• Durable power of attorney for Health Care.
• Living Will
• Last will and testament.
• Clients Bill of Rights.

Answer - A&B. Both the durable power of attorney for health care and the living will are examples of advance directives. Advance directives are documents prepared that specify the client wishes regarding health care treatments resuscitation and life support measures, and Life Care, and other specific wishes should the client become incapacitated in the future. the last will and testament goes into effect after the patient is deceased. The clients Bill of Rights outlines the rights of a client receiving medical treatment and is not an advance directive.

• Which statements are true regarding advance

directives? Select all that apply.

• Advance directives are used as guidelines for client treatment should the

client's family deem them necessary.Be. Advance directives are legally binding documents.

• Advance directive should be placed in the client's medical record.
• Advance directive specify client's wishes for healthcare treatment should the

client become incapacitated.Answer - b c and d. Advance directives are legally binding, should be placed in the client's medical record. The document details wishes for treatment should the client become an able to make informed Health Care decisions.

• it is the nurses responsibility to act as client Advocate.

What is the definition of client advocacy?

• Advocacy is to inform the client to accept Medical Treatments that conflicts

with the class phillipe's because Healthcare team knows what is best for the client.

• Advocacy is the act of arguing or negotiating on behalf of a particular issue,

idea, or person.

• Advocacy is providing Assurance to the client that a surgical procedure will be

successful and will achieve the desired outcome.

• Advocacy is informing the client that the client does not have the right to refuse

medical treatment in certain circumstances.Answer - B. Advocacy is the act of arguing or negotiating on behalf of a particular issue, idea, or person. The nurse plays an important role as the clients advocate.

• An intubated client admitted to the Intensive Care Unit

appears anxious and fearful of the equipment in the room. The nurse observes this and takes the time to explain each piece of equipment and its role in providing care to the client. This is an example of the nurse acting as a client Advocate by...

• Providing information to the client and fostering a sense of security.
• Promoting client privacy.
• Assuring client safety.
• Ensuring the client's wishes for treatment are followed.

Answer - a. The nurse assesses a client Advocate by providing information to the client to alleviate fear and Foster a sense of security.

• The nurse sees that a new medication noted in a recent

medication order is on The Client List of allergies. And the role of patient advocate what actions should the nurse take to ensure client safety? Select all that apply.A.Document the medication with times and doses to be given, then administer the medication is ordered.

• Notify the physician immediately that the medication ordered is on The Client

List of medication allergies.

• Discontinue the medication on the client's medication administration record.
• Check the client's allergy band against the list of client allergies documented in

the medical record.Answer - b c and d. Administration of a medication that the client is allergic to could result in harm to the client. The Physician should be notified immediately, the medication should be discontinued on the medication administration record, and the client's allergy band should be checked against the list of allergies documented for accuracy.

• An elderly client from a long-term care facility arrives

in the emergency department by ambulance with alter level of Consciousness. The Physician instructs the respiratory therapist to prepare for intubation. The nurse discovers a do not resuscitate bracelet on the client's risk during the initial assessment. Which immediate action should the nurse take to appropriately advocate for the client?

• Assist with the respiratory therapist to prepare the client for immediate

intubation.

• attempt to contact the client's family
• Notify the physician immediately of the clients DNR bracelet.
• Notify the dietitian immediately of the clients DNR bracelet.

Answer - C . The nurse should immediately notify the physician upon discovering the clients DNR bracelet. reaching the client's family allows the family to be with the client to provide additional support, but this should be done after notifying the physician.