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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?

A.

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

B.

Explain that living wills cannot be followed by emergency personnel.

C.

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

D.

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.
 


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Related Questions

Correct Answer is A,D,B,C

Explanation

  1. Complete a focused assessment: The first step in managing a patient with abdominal pain and other symptoms is to perform a comprehensive assessment. This will help identify the cause of the symptoms and guide subsequent interventions.
  2. Offer PRN pain medication: Once the immediate risks have been addressed, managing the patient’s pain is a priority. However, the choice of pain medication will depend on the results of the assessment.
  3. Send the emesis sample to the lab: Sending the emesis sample to the lab can provide valuable information about the cause of the patient’s symptoms. However, this is not as urgent as the other interventions.
  4. Elevate the head of the bed: Elevating the head of the bed can help reduce the risk of aspiration, especially in a patient who has vomited. This should be done as soon as possible.

Correct Answer is C

Explanation

Choice A rationale
Activating the synchronization mode is important during cardioversion to avoid delivering a shock during the vulnerable period of cardiac repolarization, which could potentially cause a life-threatening arrhythmia. However, it is not the most crucial action.
Choice B rationale
Choosing a monitor lead with a tall R wave can help ensure that the cardioverter-defibrillator can sense the patient’s intrinsic cardiac activity. However, this is not the most crucial action.
Choice C rationale
Administering the prescribed sedative is the most crucial action before initiating cardioversion. Sedation is necessary to ensure patient comfort and cooperation during the procedure, as cardioversion can be painful.
Choice D rationale

Verifying the prothrombin time (PT) is important in patients receiving anticoagulation therapy, as atrial fibrillation increases the risk of thrombus formation. However, it is not the most crucial action before initiating cardioversion.

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