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 B

Explanation

A. Marking an outline of the "olive-shaped mass" in the right epigastric area is important for diagnosis, but not a priority pre-operatively.
B. Initiating a continuous infusion of IV fluids is crucial to ensure the infant is properly hydrated before the procedure, as pyloric stenosis can cause severe dehydration.
C. Monitoring the amount of intake and the infant's response to feedings is part of ongoing care, but immediate pre-operative hydration takes precedence.
D. Instructing parents regarding care of the incisional area is necessary post-operatively, not before the surgery.

A. Suction the client to clear the airway B. Restrain the client with soft restraints C. Perform a 12-lead electrocardiogram D. Have a manual resuscitation bag at the bedside E. Ask the client about other medications she takes F. Take an initial respiratory rate

Correct Answer is ["E","F"]

Explanation

A. Suctioning the client to clear the airway is not directly related to the administration of morphine and is typically not a routine precaution unless the patient has a specific need.
B. Using soft restraints is not a standard safety measure for morphine administration and could be considered if the patient has a history of confusion or agitation, but there is no such indication in this scenario.
C. Performing a 12-lead electrocardiogram is not a standard procedure for ensuring the safe administration of morphine and is usually done for cardiac assessment.
D. Having a manual resuscitation bag at the bedside is a good practice in case of an emergency but is not specific to morphine administration safety.
E. Asking the client about other medications she takes is crucial to prevent drug interactions, as morphine can interact with many medications, potentially leading to adverse effects.
F. Taking an initial respiratory rate is important because morphine can cause respiratory depression, and it is essential to have a baseline to monitor for any changes after administration.

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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

A6-week-old infant with pyloric stenosis is scheduled for a pyloromyotomy, Which pre- operative nursing action has highest priority?

Correct Answer is B

Explanation

Correct Answer is ["E","F"]

Explanation

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