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 A
Explanation
A. The client's desire to go home so soon after a significant medical event like an MI suggests a possible denial of the severity of his condition and an unwillingness to acknowledge the
need for further medical care and recovery time.
B. While decisional conflict due to stress could be a concern, the client's behavior does not directly indicate stress about making decisions, but rather a disregard for the gravity of his recent health event.
C. Deficient knowledge of lifestyle changes is likely an issue for someone who has just experienced an MI, but the immediate behavior of wanting to leave the hospital does not directly relate to a lack of knowledge about necessary lifestyle changes.
D. Anxiety related to the treatment plan could be present, but the client's behavior of wanting to leave the hospital suggests a coping mechanism of denial rather than anxiety about the treatment itself.
Correct Answer is C
Explanation
A: An adolescent with multiple contusions due to a fall that occurred 2 days ago can be managed by the PN as the condition is stable and does not require the advanced skills of an RN.
B: A 75-year-old client with renal calculi who requires urine straining can also be assigned to the PN because urine straining is a task within the PN's scope of practice.
C: A 30-year-old depressed client who admits to suicide ideation requires the expertise of an RN due to the need for continuous assessment, potential for crisis intervention, and the complexity of care needed.
D: A 64-year-old client who had a total hip replacement the previous day would typically be stable post-operation and could be managed by the PN, with the RN available for any complications that may arise.
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