Nokea
A patient has completed a living will stating that he does not want intubation, mechanical ventilation, or artificial nutrition/hydration should he become unable to communicate his preferences related to medical care. However, the patient's adult children have expressed their opposition to the patient's wishes. Which are appropriate nursing actions? Select all that apply.
- A. Notify the patient's physician, the nursing supervisor, and the risk manager.
- B. Explain to the patient's family that the living will cannot be changed at this point.
- C. Encourage the family to discuss their feelings to try to resolve this issue.
- D. Request a consult with the facility ethics committee if needed.
- E. Advise the patient to just go along with the wishes of his adult children.
Correct Answer: A, C, D
Rationale: Notifying leadership (A), encouraging family discussion (C), and requesting an ethics consult (D) respect the client’s autonomy while addressing family concerns. Stating the will cannot be changed (B) is incorrect, and advising compliance with family (E) violates autonomy.
You may also like to solve these questions
The emergency department (ED) nurse is caring for a client who just arrived with a major thermal burn to 22.5% of the total body surface area (TBSA). Place the following actions in the order in which they need to be performed, starting from first to last.
- A. Establish a large bore peripheral vascular access device to unburned skin.
- B. Insert an indwelling urinary catheter to maintain urinary output 0.5 mL/kg/hr.
- C. Administer tetanus prophylaxis as prescribed.
- D. Administer supplemental oxygen if indicated and cover burns with sterile gauze.
- E. Assess the client's airway, breathing, and circulation and obtain vital signs.
- F. Administer prescribed isotonic fluids intravenously to maintain fluid balance.
Correct Answer: E, D, A, F, B, C
Rationale: Initial assessment of airway, breathing, circulation (E) ensures stability, followed by oxygen and burn coverage (D) for hypoxia prevention. IV access (A) and fluids (F) address shock, catheter insertion (B) monitors output, and tetanus prophylaxis (C) is last, as it’s preventive.
The nurse is teaching a group of students about incident reports. Which of the following situations would require an incident report? A visitor. Select all that apply.
- A. refusing to wear personal protective equipment (PPE).
- B. adjusting a client's infusion pump.
- C. requesting that their family member get pain medication.
- D. assisting their family member with brushing their teeth.
- E. stating that they fell while using the bathroom.
Correct Answer: A, B, E
Rationale: Refusing PPE (A), adjusting an infusion pump (B), and falling in the bathroom (E) are safety incidents requiring reports, as they pose risks or indicate harm. Requesting pain medication (C) and assisting with tooth brushing (D) are not reportable unless escalated.
The nurse is reviewing leadership and management concepts with a student nurse. The student nurse demonstrates understanding if they made which of the following statements? Select all that apply.
- A. Battery is an intentional touching of another's body without the other's consent.'
- B. Assault is when the nurse makes a verbal or physical threat.'
- C. Unintentional torts include negligence and malpractice.'
- D. Defamation is presenting false credentials for employment.'
- E. Occurrence reports reduce the liability for a negligent tort.'
Correct Answer: A, B, C
Rationale: Battery (A) is non-consensual touching, assault (B) is a threat, and negligence/malpractice (C) are unintentional torts, all correct. Defamation (D) involves false statements harming reputation, not credentials, and occurrence reports (E) document but don’t reduce liability.
The nurse has administered prescribed medications to assigned clients. Which follow-up assessment requires immediate follow-up? A client who received prescribed
- A. intravenous hydromorphone for chronic back pain and is drowsy.
- B. intravenous metoclopramide for nausea and vomiting and now has involuntary movements of the jaw.
- C. intravenous dexamethasone for chronic bronchitis reporting perineal itching.
- D. nitroglycerin infusion for chest pain and reports a headache.
Correct Answer: B
Rationale: Involuntary jaw movements after intravenous metoclopramide (B) indicate extrapyramidal symptoms, a serious adverse reaction that may progress to dystonia, requiring immediate intervention like stopping the drug or administering an antidote (e.g., diphenhydramine). Drowsiness with hydromorphone (A), perineal itching with dexamethasone (C), and headache with nitroglycerin (D) are expected side effects and less urgent.
The nurse has received the following prescriptions for newly admitted clients. Which medication should the nurse administer first?
- A. Subcutaneous (SubQ) epoetin for anemia
- B. oxycodone by mouth (PO) for pain control
- C. Intravenous (IV) fluids for sepsis
- D. Intramuscular (IM) hydroxyzine for anxiety
Correct Answer: C
Rationale: IV fluids for sepsis (C) are the priority to restore perfusion and prevent organ failure. Epoetin (A) addresses chronic anemia, oxycodone (B) manages pain, and hydroxyzine (D) treats anxiety, all less urgent than sepsis.