A client on the cardiac telemetry unit unexpectedly begins manifesting ventricular fibrillation and 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.
Seek clarification of the type of advance directive the client has.
Check the client's arm for a "Do Not Resuscitate" (DNR) bracelet.
Explain that living wills cannot be followed by emergency personnel.
The Correct Answer is B
A. While scheduling a client and family conference may be necessary to discuss the plan of care, the immediate concern is to determine the type of advance directive the client has and whether it includes preferences regarding resuscitation.
B. This is the most appropriate action because it addresses the family member's concern and ensures that the client's wishes regarding resuscitation are understood and followed.
C. While checking for a DNR bracelet is important, it does not address the family member's question about why the code was called despite the client having a living will.
D. This statement is incorrect. Living wills can guide decision-making regarding end-of-life care, including resuscitation, depending on the legal requirements and documentation in place.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale for A: Monitoring blood glucose levels is important in septic patients as hyperglycemia can occur due to stress response, and insulin resistance may develop. However, it is not the most critical intervention for immediate stabilization.
Rationale for B: Maintaining strict intake and output is crucial for a patient in septic shock because fluid balance is a key component in managing shock. Accurate measurement of intake and output ensures appropriate fluid resuscitation, which is vital for maintaining blood pressure and organ perfusion.
Rationale for C: Keeping the head of the bed raised 45 degrees can help prevent aspiration, which is particularly important in patients who are at risk of gastrointestinal bleeding or those who are sedated. However, this is not the primary intervention for septic shock management.
Rationale for D: Assessing the warmth of extremities can provide information about peripheral circulation and may indicate the effectiveness of cardiac output. Nevertheless, it is not the most immediate concern in the management of septic shock.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"E","dropdown-group-3":"A"}
Explanation
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Dyspnea: Dyspnea, or difficulty breathing, can be a symptom of an adverse reaction such as an allergic reaction, anaphylaxis, or cardiovascular issues. It indicates a severe reaction that affects the respiratory system and requires immediate attention.
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Nausea: Nausea is a common symptom of adverse reactions to medications or other substances. It can accompany other symptoms like dizziness or headache and indicates that the client is experiencing an ongoing negative reaction to a treatment or exposure.
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Headache: A headache can be a manifestation of various adverse reactions, including those related to medication or changes in blood pressure. It is a significant symptom that may indicate worsening of the client's condition or an ongoing adverse reaction that needs to be addressed.
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