A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement)

The client's need for pain medication should be determined.

The nurse manager should be updated on the client's status

The client's status should be conveyed to the chaplain.

The impending signs of death should be documented

Answer and Explanation

The Correct Answer is A

A. Determining the client's need for pain medication is a priority to ensure comfort and manage symptoms as the client approaches end of life.
B. Updating the nurse manager on the client's status is important, but it is not the priority action in terms of direct client care.
C. Conveying the client's status to the chaplain may be part of holistic care, but the immediate physical needs of the client take precedence.
D. Documenting the impending signs of death is essential for medical records, but addressing the client's comfort needs is the priority.

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Correct Answer is D

Explanation

A. Replacing the IV site with a smaller gauge does not address the issue of the client picking at the dressing and tape. It is important to address the primary concern, which is the integrity of the abdominal incision dressing.

B. Applying wrist restraints should be avoided unless absolutely necessary due to the risk of physical and psychological harm to the client. It is not the first-line intervention for addressing dressing and tape disruption.

C. Leaving the lights on in the room at night may help reduce confusion in some clients with dementia but does not address the immediate issue of the disrupted abdominal dressing and IV site.

D. Redressing the abdominal incision is the priority intervention to maintain the integrity of the surgical site and prevent infection. It also addresses the issue of the client picking at the dressing and tape, which could lead to further complications.

A. Encourage the nurse to flush the tube with more water. B. Instruct the nurse to administer each medication separately. C. Add the liquid volumes when documenting fluid intake. D. Confirm that the nurse determined the amount of gastric residual. E. Advise the nurse to use the plunger when giving medications

Correct Answer is ["B","C","D"]

Explanation

A. Encouraging the nurse to flush the tube with more water is not mentioned as a necessary action based on the information provided. Flushing with water is typically done to ensure the tube
remains patent and to prevent medication interactions within the tube, but the scenario does not indicate that the nurse failed to do this or that there was an issue with tube patency.

B. Instructing the nurse to administer each medication separately is correct. This is important to prevent drug interactions within the tube and to ensure accurate dosing. Administering
medications separately allows for proper absorption and can prevent complications such as clogging of the tube.

C. Adding the liquid volumes when documenting fluid intake is correct. It is essential to account for all sources of fluid intake to maintain accurate fluid balance records. Medications
administered through a gastrostomy tube contribute to the patient's overall fluid intake and must be included in the documentation.

D. Confirming that the nurse determined the amount of gastric residual is correct. This is a critical step to ensure that the patient is tolerating the feedings and to prevent complications such as
aspiration. Gastric residual volume can indicate if the patient's digestive system is processing the feeding appropriately.

E. Advising the nurse to use the plunger when giving medications is not necessary in this context. The use of a plunger can be appropriate in some situations, but the scenario does not provide enough information to suggest that the nurse had difficulty administering the medications that would require the use of a plunger. Additionally, using a plunger can increase the risk of tube
damage or patient discomfort.

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A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

The charge nurse observes a new nurse demonstrate the administration of two different liquid medications through a gastrostomy tube used for continuous feedings, as seen in the video. Which action(s) should the charge nurse take? (Select all that apply)

Correct Answer is ["B","C","D"]

Explanation

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