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","D","E"]
Explanation
A. While managing pain is important, the client did not report significant pain, making it a lower priority in this scenario.
B. Quitting smoking is crucial for the client's respiratory health, especially given the history of smoking and current respiratory symptoms.
C. There is no indication that the client is at risk of skin breakdown; thus, it is not a priority in the immediate discharge plan.
D. Maintaining an oxygen saturation of 96% without supplemental oxygen is a direct indicator of improved respiratory function and a key goal for discharge.
E. Being afebrile for 24 hours would indicate that the infection is under control, which is a primary concern for discharge after presenting with flu-like symptoms.
Correct Answer is C
Explanation
A. Remind the UAP to apply a fitted respirator mask before entering the client's room: While respiratory protection is important when caring for a client with influenza, the situation described does not warrant the use of a fitted respirator mask for the UAP. Standard precautions, including wearing a face mask, gloves, and gown, are typically sufficient for influenza.
B. Instruct the UAP to notify the nurse of any changes in the client's respiratory status: This instruction is important for overall client monitoring but does not directly address the issue of appropriate personal protective equipment (PPE for the UAP.
C. Review the need for the UAP to wear a face mask while in close contact with the client: Correct! The nurse should remind the UAP of the importance of wearing a face mask when providing care to a client with influenza. Face masks help prevent the spread of respiratory droplets and protect both the client and healthcare workers from infection.
D. Assign the UAP to provide care for another client and assume full care of the client: While reassigning the UAP is an option if they are not following proper infection control procedures, it's important to address the issue directly by reminding them of the need for appropriate PPE.
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