Nokea
A 51-year-old client with amyotrophic lateral sclerosis (Lou Gehrig disease) is admitted to the hospital because his condition is deteriorating. The client tells the nurse that he wants a do-not-resuscitate (DNR) order. The nurse should provide the client with which information?
- A. Oral consent is not sufficient, and the client's request will be honored by all healthcare providers.
- B. Consent must be obtained from the family.
- C. The DNR request should be discussed with the healthcare provider, who will write the order.
- D. The healthcare provider makes the final decision about a DNR request.
Correct Answer: C
Rationale: When a client requests a DNR order, the nurse should contact the healthcare provider so that the provider may discuss the request with the client. A DNR order should be written, not verbal, following agency and state guidelines. Therefore, the correct answer is that the DNR request should be discussed with the healthcare provider, who will write the order. Option A is incorrect as oral consent is not sufficient for a DNR order. Option B is incorrect because the client, not the family, has the authority to request a DNR order. Option D is incorrect because the healthcare provider discusses the request with the client but does not make the final decision.
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A nurse is taking a morning break with the unit secretary in the nurses' lounge. The unit secretary says to the nurse, 'I read in Mr. Gage's medical record that he has gonorrhea.' How should the nurse respond to the secretary?
- A. Yes, he does, but be sure not to discuss this with anyone else.
- B. Yes, that's why we've imposed contact precautions.
- C. We can't discuss a client's medical condition.
- D. Oh, really? I didn't see that!
Correct Answer: C
Rationale: A client's medical condition is confidential and should never be discussed with anyone other than the client and the client's healthcare provider. Therefore, the nurse must tell the unit secretary that the client's condition is not to be discussed. Choices A and B confirm the client's disease, which is inappropriate as it breaches patient confidentiality. Choice D promotes further discussion of the client's condition, which is also inappropriate. The correct response is to firmly state, 'We can't discuss a client's medical condition,' to uphold patient privacy and confidentiality.
A nurse on the night shift is making client rounds. When the nurse checks a client who is 97 years old and has successfully been treated for heart failure, he notes that the client is not breathing. If the client does not have a do-not-resuscitate (DNR) order, the nurse should take which action?
- A. Administer cardiopulmonary resuscitation (CPR)
- B. Call the client's health care provider
- C. Administer oxygen to the client and call the health care provider
- D. Contact the nursing supervisor for directions
Correct Answer: A
Rationale: Administering cardiopulmonary resuscitation (CPR) is the appropriate action when a client is not breathing and does not have a do-not-resuscitate (DNR) order. CPR is considered an emergency treatment that can be provided without client consent in life-threatening situations. Calling the health care provider or nursing supervisor for directions, as well as administering oxygen without addressing the lack of breathing, would delay critical life-saving interventions. Therefore, administering CPR is the most urgent and necessary action to perform in this scenario.
Nurse Ann tells nurse Christine that one of her client's status is declining but that she will do her best to juggle her other two clients. Which action is most appropriate?
- A. Nurse Christine should offer to give medications to Nurse Ann's other two clients.
- B. Nurse Christine should inform their supervisor that assignments may need to be changed.
- C. Nurse Christine should ask other nurses who might be able to help Nurse Ann.
- D. Nurse Ann should try not to burden other nurses and continue caring for her assigned clients.
Correct Answer: B
Rationale: In this situation, when Nurse Ann informs Nurse Christine that a client's status is declining and she needs to attend to them, the most appropriate action for Nurse Christine is to inform their supervisor that assignments may need to be changed. By informing the supervisor, necessary adjustments can be made to ensure proper care for all clients. Offering to give medications to Nurse Ann's other two clients (choice A) may not address the underlying issue of a declining client and could lead to a delay in care. Asking other nurses for help (choice C) might not be the most efficient solution, as the supervisor is responsible for reassigning tasks. Nurse Ann continuing to care for all her assigned clients (choice D) may compromise the quality of care provided to the declining client and may spread her too thin, impacting all clients negatively.
Which of these statements is true regarding advance directives?
- A. They must be reviewed and re-signed every 10 years in order to remain valid.
- B. An advance directive is legally valid in every state, regardless of the state it was created in.
- C. A physician must determine when a client is unable to make medical decisions for themselves.
- D. They cannot be honored by EMTs (emergency medical technicians) unless signed by a doctor.
Correct Answer: D
Rationale: The correct statement is that advance directives cannot be honored by EMTs unless they are signed by a doctor. EMTs are required to provide emergency care to a client, irrespective of their advance directive status, unless the directive has been signed by a doctor. When a client is brought to the hospital, physicians will assess the client and implement the advance directive if necessary. Advance directives do not need to be reviewed and re-signed every 10 years to remain valid; they remain in effect until changed. While advance directives are legally valid in most states, some states may not honor those created in other states, so it's advisable to check the new state's policies if a client moves. Additionally, it typically requires two physicians, not just one, to determine if a client is unable to make medical decisions for themselves.
A nurse and a nursing assistant enter a client's room to provide care and find the client lying on the floor. Which action should the nurse take first?
- A. Ask the nursing assistant to complete an incident report
- B. Check the client's level of consciousness and vital signs
- C. Contact the unit secretary on the intercom and ask that the client's health care provider be called
- D. Ask the nursing assistant to assist in getting the client back to bed
Correct Answer: B
Rationale: When a client sustains a fall, the nurse must first assess the client. The nurse should check the client's level of consciousness and vital signs to determine the severity of the situation and provide appropriate care promptly. This immediate assessment is crucial in ensuring the client's immediate needs are addressed. Asking the nursing assistant to complete an incident report (choice A) is not the priority as the client's condition needs immediate attention. Contacting the unit secretary to call the client's health care provider (choice C) can be done after the initial assessment has been completed. Asking the nursing assistant to assist in getting the client back to bed (choice D) should only be considered after ensuring the client is stable and safe to move.