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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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

A. A blood glucose level of 90 mg/dL is within the normal reference range of 74 to 106 mg/dL, so it is not a concern.
B. A potassium level of 4 mEq/L is also within the normal reference range of 3.5 to 5.0 mEq/L, so it does not need to be reported.
C. Although the hemoglobin level of 13 g/dL is below the reference range provided, it is not critically low and may not be urgent unless the patient has symptoms of anemia or other related issues.
D. A serum creatinine level of 5 mg/dL is significantly higher than the normal reference range of 0.5 to 1.1 mg/dL. This indicates renal impairment, which could affect the patient's ability to clear medications used during surgery and could lead to postoperative complications. Therefore, it is crucial to report this finding to the surgeon immediately.

A. Increase in breath sounds. B. Absence of fine crackles. C. Absence of coarse crackles. D. Increase in respiratory rate.

Correct Answer is B

Explanation

A. An increase in breath sounds may suggest improved airflow, but it does not necessarily indicate effective mobilization of secretions.
B. Absence of fine crackles indicates that there are no longer small airway secretions or fluid in the lungs, suggesting that the chest physiotherapy was effective in mobilizing secretions.
C. While the absence of coarse crackles is also a positive finding, fine crackles specifically indicate fluid or secretions in the small airways, making their absence a more direct indicator of the effectiveness of chest physiotherapy.

D. An increase in respiratory rate may indicate respiratory distress or worsening of the condition, rather than effectiveness of the chest physiotherapy in mobilizing secretions.

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

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?

Correct Answer is B

Explanation

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 collecting a heelstick blood specimen for a neonatal screen, which includes thyroxine (T4) and thyroid stimulating hormone (TSH) levels, prior to the discharge of a 2-day- old client. When the parents ask why these tests are being conducted, which explanation should the nurse provide?

The nurse observes an unlicensed assistive personnel (UAP) who is preparing to provide personal care for a client who requires contact precautions. The UAP has applied a gown and gloves and secured the tops of the gloves over the gown sleeves. Which action should the nurse take?

The nurse is assigned to care for a client diagnosed with psoriasis. Which behavior by the nurse addresses this client's psychosocial need for acceptance?

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

After receiving a change of shift report for clients on a medical surgical unit, which task should the nurse assign to the practical nurse (PN)?