A client who has a do-not-resuscitate (DNR) order is admitted to the hospital for pneumonia. The client's condition deteriorates and he becomes unresponsive. The nurse notices that his heart rate is dropping and his blood pressure is low.
Which of the following actions should the nurse take?
Initiate cardiopulmonary resuscitation (CPR) and call a code blue.
Administer oxygen via nasal cannula and monitor his vital signs.
Notify the health care provider and the client's family of his status.
Continue to provide comfort measures and emotional support to the client.
The Correct Answer is D
The nurse should continue to provide comfort measures and emotional support to the client, as well as respect his DNR order, which means that no resuscitation measures should be attempted if he experiences cardiac or respiratory arrest.
Option A is incorrect because initiating CPR and calling a code blue would violate the client's DNR order and his right to refuse treatment.
Option B is incorrect because administering oxygen via nasal cannula may be considered a form of resuscitation, depending on the client's wishes and goals of care; moreover, monitoring his vital signs may not be necessary or beneficial at this stage of his illness. Option C is incorrect because notifying the health care provider and the client's family of his status may not be a priority at this time; rather, the nurse should focus on providing compassionate care to the client until he dies.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Palliative care is a holistic approach to care that focuses on improving the quality of life for clients with serious illnesses and their families. It addresses physical, emotional, social, and spiritual needs, and can be provided at any stage of illness, along with curative treatments.
Option B is incorrect because palliative care does not necessarily involve withdrawing treatments or medications, unless they are causing more harm than benefit.
Option C is incorrect because palliative care does not aim to cure the disease, but rather to manage the symptoms and enhance comfort.
Option D is incorrect because palliative care is not the same as hospice care, which is a specific type of palliative care for clients who have a life expectancy of six months or less and have decided to forego curative treatments.
Correct Answer is C
Explanation
The nurse should instruct the family member to call the hospice nurse first to get an order for a higher dose of morphine, if needed. The hospice nurse can assess the client's pain level, vital signs, and response to the medication, and adjust the dose accordingly.
Option A is incorrect because although respiratory rate is one of the factors to monitor when administering opioids, it is not the only one; other factors include level of consciousness, oxygen saturation, and presence of adverse effects. Moreover, the family member should not increase the dose of morphine without consulting the hospice nurse.
Option B is incorrect because although respiratory depression is a potential side effect of opioids, it is not a common cause of death in clients receiving palliative care; rather, opioids are considered safe and effective for managing pain and dyspnea in dying clients, as long as they are prescribed and administered appropriately.
Option D is incorrect because tolerance and dependence are not major concerns in clients receiving palliative care; rather, the goal is to provide adequate pain relief and comfort for the client.
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