Author Question: A nurse is caring for clients when a peer tells the nurse to get ready to take a new admission who ... (Read 21 times)

elizabeth18 · **on:** Jul 22, 2018

A nurse is caring for clients when a peer tells the nurse to get ready to take a new admission who is on the way. What action will the first nurse take in this situation?

1. Approach the charge nurse or manager for confirmation
2. Set up for the admission
3. Refuse the assignment
4. Ask another nurse to take the assignment

Question 2

A nurse aide reports to the nurse that the 87-year-old client is not breathing well and has cold and mottled skin. The client has a living will and requests comfort measures only. The nurse's action to care for this client would be to:

1. Withhold pain medication, hygiene, and nutrition until the client dies.
2. Contact the physician for orders to control the client's breathing.
3. Ask the family what they want to be done for the client.
4. Instruct the nurse aide to provide personal hygiene and skin care as outlined in the care plan.

Liamb2179 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

1. Approach the charge nurse or manager for confirmation

Rationale:
The second nurse is inappropriately trying to use line authority. The peer can advise, using staff authority, but not direct, which is used in line authority. The appropriate action by the first nurse is to check with the person who does have line authority or who is able to make this type of decision. Setting up for the admission without checking with authority could cause confusion on the unit and a gap in client care. Refusing the assignment may not be in the best interest of the unit or current clients as a conflict could ensue. Asking a third nurse to take the assignment is not within the purview of the nurse and could result in more unit confusion.

Answer to Question 2

4. Instruct the nurse aide to provide personal hygiene and skin care as outlined in the care plan.

Rationale:
Comfort measures only indicate that the client does not want extraordinary measures to sustain life. This does not mean that nursing care ceases but that nursing care to provide patient comfort is intensified and maintained through the end stages of the client's life. Withholding pain medication, hygiene, and nutrition would be neglecting the patient and not providing comfort measures. Asking the family what they want to be done is inappropriate when a client has written a living will. Contacting the physician to intervene to control respiration is considered adding extraordinary measures and is inappropriate, as is going against the client's written wishes when a living will is present and in force.