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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","H"]
Explanation
A. Chesty: Not a priority compared to monitoring vital signs and ensuring adequate oxygenation.
B. Start oxygen 3 L via nasal cannulA Increased oxygen flow is necessary to manage the
client's respiratory distress and history of smoking. Correct Answer: 3 L, not 1 L as initially listed.
C. Acetaminophen 350 mg PO q4h for temperature greater than 101 F (38.3°C): Important for fever management but not the first priority in acute respiratory distress.
D. Normal saline 150 ml/hour: Helps maintain hydration but is secondary to respiratory support in this scenario.
E. NPO: Not applicable as there is no immediate need for surgery or risk of aspiration currently indicated.
F. Start an IV: Important for medication administration and fluid balance but follows after ensuring respiratory function.
G. Sputum culture: Useful for diagnosing the cause of respiratory symptoms but not a first- line action.
H. Place the client on a cardiorespiratory monitor: Essential for continuously assessing the client's respiratory and cardiac status due to difficulty breathing.
Correct Answer is B
Explanation
A. Support stockings may help with peripheral edema, but they do not address the underlying issue of hypoalbuminemia and its consequences.
B. Adequate protein intake is crucial for increasing serum albumin levels, which can help reduce edema and improve the client's nutritional status. This intervention addresses the root cause of
the client's symptoms.
C. Evaluating the patency of the AV graft is important for long-term planning of hemodialysis access, but it is not the immediate priority given the client's current nutritional status and symptoms.
D. Fluid restriction is important in managing peritoneal dialysis patients, but it does not address the immediate concern of hypoalbuminemia and its effects on the client's health.
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