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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Wearing an N95 respiratory mask is not typically required for routine care of a toddler with respiratory syncytial virus unless performing procedures that generate aerosols.
B. Negative pressure rooms are generally reserved for patients with airborne infections like tuberculosis; respiratory syncytial virus does not typically require isolation in a negative pressure room.
C. Using a designated stethoscope helps prevent the spread of infection to other patients by avoiding cross-contamination.
D. Removing the disposable gown after leaving the toddler's room is appropriate for maintaining infection control but is not specific to caring for a toddler with respiratory syncytial virus.

A. Provide only distilled water. B. Document abdominal girth. C. Offer a high protein diet. D. Use a cushion when sitting.

Correct Answer is B

Explanation

A. Provide only distilled water. Providing only distilled water is not appropriate in this situation.
The client's weight gain and electrolyte imbalance indicate the need for careful monitoring and intervention, but restricting fluid intake to distilled water alone may not address the underlying issues adequately.
B. Document abdominal girth. Documenting abdominal girth is important to assess for signs of ascites, which can occur in hepatic failure. A sudden weight gain and elevated blood pressure may indicate fluid retention, and documenting abdominal girth can provide additional information about fluid accumulation in the abdomen.
C. Offer a high protein diet. While nutritional support is important for clients with hepatic failure, offering a high protein diet may not be appropriate if the client has an electrolyte imbalance. Protein intake should be balanced and monitored carefully to avoid exacerbating the imbalance.
D. Use a cushion when sitting. Using a cushion when sitting may be beneficial for comfort, but it does not directly address the identified issues of electrolyte imbalance, elevated blood pressure, and weight gain. The priority is to assess and address these concerns through appropriate
interventions such as documenting abdominal girth and addressing fluid retention.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a toddler who has respiratory syncytial virus. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

The nurse identifies an electrolyte imbalance, an elevated blood pressure, and a weight gain of 4.4 lbs (2 kg) in 24 hours for a client with hepatic failure. Which intervention should the nurse include in the plan of care?

Correct Answer is B

Explanation

Which assessment finding is most important when planning to provide a complete bed bath to a bedfast client?

Exhibits here Click to indicate if the listed manifestation of abuse is consistent with physical abuse, abandonment, or neglect. Each row must have only one response option selected.

The nurse is providing discharge instructions to a client with gout in the left great toe who received a prescription for prednisone 30 mg by mouth to be administered each day. Which symptom should the nurse explain is most important for the client to report to the healthcare provider?

A client with chronic obstructive pulmonary disease (COPD) receives a prescription for chest physiotherapy (CPT) to help mobilize secretions. Following the therapy, which finding indicates to the nurse that the intervention was effective?

The nurse is monitoring a client with Cushing's disease in the postanesthesia care unit (PACU) after a hypophysectomy. Which intervention is most important for the nurse to include in the client's plan of care?

The nurse is preparing to administer a histamine 2-receptor antagonist to a client with peptic ulcer disease. What is the primary purpose of this drug classification?

Exhibits The nurse should place the client in a position to promote