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 C

Explanation

A. A sluggish blood return: While a sluggish blood return may indicate potential issues with the IV line, it does not require immediate intervention unless accompanied by other signs of
complications.
B. Cool sensation above the site: Cool sensation above the site may indicate impaired circulation, but it is not as concerning as other findings requiring immediate intervention.
C. Iced streak tracking the vein: Correct! An iced streak tracking the vein suggests infiltration of IV fluids into the surrounding tissue, which can cause tissue damage and compromise the
effectiveness of the IV therapy. Immediate intervention is needed to prevent further complications.
D. Circumferential skin irritation: Circumferential skin irritation may indicate an allergic reaction or contact dermatitis, which requires attention but is not as urgent as an infiltration.

A. A 16-year-old client diagnosed with major depression who refuses to participate in group. B. A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby. C. An 18-year-old client with antisocial behavior who is being yelled at by other clients. D. A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack.

Correct Answer is C

Explanation

A. A 16-year-old client diagnosed with major depression who refuses to participate in group:

While refusal to participate may warrant assessment and intervention, it does not indicate immediate danger or escalation.

B. A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby: Pacing behavior may indicate anxiety or agitation, but it does not necessarily require immediate attention unless there are signs of escalating behavior or safety concerns.

C. An 18-year-old client with antisocial behavior who is being yelled at by other clients: Correct! The client with antisocial behavior being yelled at by other clients indicates a potential conflict or safety issue that requires immediate intervention to prevent escalation or harm to the client or others.

D. A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack: Refusal to eat is concerning in a client with anorexia nervosa, but it does not pose an immediate threat to safety compared to the situation involving potential conflict or aggression.

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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

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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