A client on the cardiac telemetry unit suddenly starts showing signs of ventricular fibrillation. The advanced cardiac life support (ACLS) team defibrillates the client, restoring a normal sinus rhythm. Later in the day, a family member Questions why the code was called, telling the nurse that the client has a living will.
How should the nurse respond?

Schedule a client and family conference to review the plan of care.

Explain that living wills cannot be followed by emergency personnel.

Check the client’s arm for a “Do Not Resuscitate” (DNR) bracelet.

Seek clarification of the type of advance directive the client has.

Answer and Explanation

The Correct Answer is D

Choice D rationale
Seeking clarification of the type of advance directive the client has is the most appropriate response. A living will typically outlines a person’s wishes for end-of-life care, but it may not specifically address emergency situations like cardiac arrest.

Choice A rationale
Scheduling a client and family conference to review the plan of care may be helpful, but it is not the immediate priority. The nurse first needs to understand the client’s wishes as outlined in their advance directive.

Choice B rationale
Explaining that living wills cannot be followed by emergency personnel is not entirely accurate. While it’s true that emergency personnel initiating resuscitative measures may not have immediate access to a person’s living will, in a hospital setting, a person’s known wishes should be respected as much as possible.

Choice C rationale

Checking the client’s arm for a “Do Not Resuscitate” (DNR) bracelet is not the most appropriate response. While some people may choose to wear such a bracelet, not all do. Furthermore, a DNR order is just one type of advance directive, and it’s important to clarify what specific directives the client has in place.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["A","B","E"]

Explanation

Choice A rationale

Monitoring the client’s white blood cell count is important in this case. An elevated white blood cell count is a common sign of infection, and regular monitoring can help assess the client’s response to treatment.
Choice B rationale
Implementing contact precautions for staff and visitors is crucial when caring for a client with a potential VRE infection. VRE is a multi-drug resistant organism that can be spread through direct contact, so strict infection control measures are necessary.
Choice C rationale
Using standard precautions and wearing a mask is generally good practice in healthcare settings to prevent the spread of infections. However, a mask is not specifically required for contact precautions with VRE456.
Choice D rationale
Explaining the purpose of a low bacteria diet is not relevant in this case. While diet can play a role in overall health and recovery, it is not a specific intervention for a client with a potential VRE infection.
Choice E rationale
Sending wound drainage for culture and sensitivity is an important step in confirming the presence of VRE and determining the most effective antibiotic therapy.

A. The patient urinates only once or twice a day. B. The patient gained 10 lb (4.5 kg) within a month. C. The patient refuses to eat their favorite meals at home. D. The patient has been drinking more fluids than usual.

Correct Answer is D

Explanation

Choice A rationale
Urinating only once or twice a day is not a typical symptom of type I diabetes mellitus. In fact, frequent urination is a common symptom of diabetes.
Choice B rationale
Rapid weight gain is not typically associated with type I diabetes mellitus. On the contrary, unexplained weight loss is a common symptom.
Choice C rationale
Refusing to eat favorite meals is not a typical symptom of type I diabetes mellitus. Changes in appetite can occur in various conditions, but they are not specific to diabetes.
Choice D rationale
Drinking more fluids than usual, also known as polydipsia, is a common symptom of type I diabetes mellitus. This is often accompanied by polyuria (frequent urination) due to high blood sugar levels.

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Naxlex Comprehensive Predictor Exams

A client with a venous ulcer, which has not responded to intravenous vancomycin treatment and is discharging pus, has been admitted with a potential infection of Vancomycin-Resistant Enterococci (VRE). Which nursing interventions should be included in the care plan? Select all that apply.

Correct Answer is ["A","B","E"]

Explanation

A school-aged patient was recently diagnosed with type I diabetes mellitus. What symptom did the patient’s parents most likely report?

Correct Answer is D

Explanation

An adolescent arrives at the emergency department (ED) with a fever and persistent lower right quadrant abdominal pain. The patient is anxious, fearful, and hyperventilating. What acid-base imbalance does the nurse anticipate the patient will develop?

Before inserting an indwelling urinary catheter, which information about the patient is most important for the nurse to obtain?

A 10-year-old child with pneumonia is receiving oxygen at 5 L/minute via a nasal cannula. When planning care for this child, what principle of oxygen administration should the nurse keep in mind?

The nurse uses the Modified Caregiver Strain Index (MCSI) and determines that the daughter is under significant stress caused by the assumption of her mother’s care.

The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized older client with an indwelling urinary catheter every two hours. Which additional action should the nurse instruct the UAP to take each time the client is turned?

A client with schizophrenia is admitted to the hospital reporting auditory hallucinations. Which query is most important for the nurse to include in the client’s assessment?