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 D
Explanation
A: Using a different sphygmomanometer would not address the underlying cause of the spasms, which is likely not related to the equipment itself.
B: Taking the blood pressure in the other arm may avoid the spasms temporarily, but it does not address the potential underlying medical issue causing the spasms.
C: Administering an antianxiety medication is not indicated as the spasms are not necessarily related to anxiety; they could be a sign of a physiological condition.
D: Reviewing the client's serum calcium level is the most appropriate action. The spasms described are indicative of Trousseau's sign, which is associated with hypocalcemia. Hypocalcemia can cause increased neuromuscular excitability, leading to spasms. It is important to identify and treat the underlying cause of the spasms, which in this case could be a calcium deficiency.
Correct Answer is B
Explanation
A. Initiating teaching for client care after discharge is incorrect. Teaching, especially initial or comprehensive education, is within the scope of practice of a registered nurse (RN), not a practical nurse (PN).
B. Using bladder ultrasound to detect urinary retention is correct. This is a task within the scope of practice for a PN, as it involves data collection and does not require independent clinical judgment.
C. Completing comprehensive assessments is incorrect. Comprehensive assessments require critical thinking and are the responsibility of the RN. PNs may collect data but do not perform initial comprehensive assessments.
D. Beginning initial sterile wound care for surgical clients is incorrect. The RN should perform the first sterile dressing change postoperatively to assess the wound properly. The PN may perform subsequent dressing changes per facility policy.
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