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. Reposition the infant every 2 hours: This ensures that all areas of the infant's skin receive equal exposure to the phototherapy light, which is important for the effective treatment of jaundice.
B. Cover with a receiving blanket: This is incorrect because the phototherapy light needs to reach the infant's skin directly. Covering the infant with a blanket would block the light and reduce the effectiveness of the treatment.
C. Perform diaper changes under the light: While it is important to minimize the time the infant is away from the phototherapy light, diaper changes should be done quickly and efficiently, not necessarily under the light, to ensure cleanliness and to prevent any potential discomfort or safety issues.
D. Feed the infant every 4 hours: Feeding the infant is important, but the frequency of feeding should be based on the infant's needs and not specifically tied to the phototherapy schedule. Additionally, frequent feeding can help promote bowel movements, which can aid in the excretion of bilirubin.
Correct Answer is C
Explanation
A. Providing pain medication to increase the client's tolerance of labor pains: Pain management is important throughout labor, but in the second stage, the focus shifts to pushing efforts and fetal expulsion. Pain medication may affect the client's ability to push effectively and may not be
indicated at this stage.
B. Assessing the fetal heart rate and pattern for signs of fetal distress: Fetal monitoring is essential throughout labor, including the second stage, to assess fetal well-being and detect signs of
distress. However, the specific intervention indicated for the second stage is assisting the client with pushing.
C. Assisting the client to push effectively so that expulsion of the fetus can be achieveD Correct!
In the second stage of labor, the cervix is fully dilated, and the focus is on pushing efforts to
facilitate the birth of the baby. The nurse plays a crucial role in supporting the client during this stage by providing guidance on effective pushing techniques and encouragement.
D. Monitoring effects of oxytocin administration to help achieve cervical dilation: Oxytocin administration is typically used in the first stage of labor to induce or augment contractions and facilitate cervical dilation. Monitoring its effects is important, but it is not a specific intervention for the second stage of labor, where the focus is on pushing and fetal expulsion.
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