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. The patient's need for pain medication should be determined. B. The nurse manager should be updated on the patient's status. C. The patient's status should be conveyed to the chaplain. D. The impending signs of death should be documented.

Correct Answer is A

Explanation

A. Determining the patient's need for pain medication is a priority to ensure the patient's comfort during the end-of-life care process. Pain management is a critical aspect of palliative care and should be addressed promptly.
B. Updating the nurse manager on the patient's status is important but is not the immediate priority. The nurse manager's awareness does not directly impact the patient's comfort or care at the moment of impending death.
C. Conveying the patient's status to the chaplain may be part of the holistic care approach and can provide spiritual support to the patient and family, but it is not the first priority in terms of the patient's immediate physical needs.
D. Documenting the impending signs of death is essential for legal and medical records; however, it is secondary to addressing the patient's immediate needs, such as pain relief.

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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

A dietitian with a prescription for no not resuscitate (DNR) begins to manifest signs of impending death. After notifying the family of the patient's status, what priority action should the nurse implement?

Correct Answer is A

Explanation

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