A client with end stage metastatic cancer has a living will stating no extraordinary measures are to be taken as death approaches, and the healthcare provider writes a "Do Not Resuscitate" (DNR) prescription. When the client begins to take gasping breaths, the nurse determines the client's oxygen saturation is 85%. Which action should the nurse implement?

Manually ventilate using a bag valve mask apparatus.

Determine if client wishes have changed.

Report client's status to the healthcare provider.

Administer oxygen via a nasal cannula.

Answer and Explanation

The Correct Answer is D

A.   Using a bag valve mask (BVM) to manually ventilate the client would be considered an extraordinary measure, which conflicts with the client's living will stating no extraordinary measures should be taken.
B.   While it's essential to ensure that the client's current wishes are respected, the client is likely unable to communicate effectively due to their condition. If the client were able to express their wishes at this stage, it might be important to confirm, but given the client's living will and the established DNR order, the primary focus should be on adhering to these documents.
C.   Reporting the client's status to the healthcare provider is important to ensure that the provider is informed about the client’s current condition and can offer guidance or make necessary adjustments in the care plan. However, if the healthcare provider is already aware of the client's living will and DNR order, this step may be secondary to following the existing orders.
D.   Administering supplemental oxygen via a nasal cannula is a palliative measure that can provide comfort without being considered an extraordinary measure. It aligns with the goal of providing symptom relief and comfort care rather than resuscitation or life-extending interventions.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Measuring body temperature is important in assessing the client’s overall condition and identifying a fever, which is common in pneumonia. However, while it provides useful information about the client's status, it is not the most urgent action compared to interventions that could immediately impact the client’s respiratory function or confirm the diagnosis.
B. Administering PRN (as needed) oxygen is crucial if the client shows signs of hypoxia or difficulty breathing. If the client's face appears cyanotic or if they are experiencing respiratory distress, this action should be prioritized to ensure adequate oxygenation.
C. A chest x-ray is essential for diagnosing pneumonia and assessing the extent of lung involvement. However, while it is critical for diagnosis, addressing immediate respiratory needs and symptoms takes precedence.
D. Obtaining sputum for culture is important for identifying the causative organism and guiding antibiotic therapy. However, this action is less urgent than ensuring the client’s immediate respiratory needs are met and confirming the diagnosis through imaging.

A. Report a mismatch of prescribed and available doses. B. Calculate the dose on hand to match the prescribed dose. C. Ask the pharmacist if another dose can be dispensed. D. Withhold the medication until the exact dose is available.

Correct Answer is A

Explanation

A. This is a critical first step when a medication dose discrepancy is identified. Reporting the mismatch alerts the appropriate personnel (such as the pharmacy or healthcare provider) to investigate and resolve the issue. This ensures that the correct dose is administered and helps prevent potential medication errors.
B. While calculating the dose on hand is important to ensure accurate dosing, this action should be secondary to reporting the issue first. Calculating the dose is part of the process to verify and adjust the dose if needed, but the primary concern is to report the discrepancy to get it addressed properly and safely.
C. Asking the pharmacist for a different dose is a valid action, but it should come after reporting the discrepancy. The pharmacist can provide guidance on whether a different dose can be dispensed and help clarify any issues with the medication.
D. Withholding the medication is an appropriate precaution if there is uncertainty about the dose, but it is not the first action to take. This step should follow the initial reporting of the discrepancy to ensure that the medication is correct and safe to administer.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted with possible pneumonia. When entering the room, the nurse observes the client's face as seen in the picture. Which prescription should the nurse implement first?

Correct Answer is B

Explanation

The electronic medication system alerts the nurse that the medication dose scanned for the client is two times higher than the dose prescribed. Which action should the nurse implement?

Correct Answer is A

Explanation

When identifying the goals to be included in a client's plan of care, the nurse should take which action?

The nurse assesses a client who has a nasal cannula delivering oxygen at 2 liters/minute. To assess for skin damage related to the cannula, what areas should the nurse observe? Select all that apply.

The client is receiving a liter of 0.9% sodium chloride with potassium chloride (KCI) 30 mEq IV to infuse over 4 hours. Which nursing action has the highest priority for this client?

When preparing to change a client's sterile dressing, the nurse pours sterile solution over a package of gauze pads as seen in the picture. Which should the nurse do next?

An older female client residing at a long-term care facility receives an enteral tube feeding bolus via percutaneous endoscopic gastrostomy (PEG) tube 6 times daily. Which interventions should the nurse implement? Select all that apply.

In assisting the family of an older adult client to determine the best living environment for the client, which factor is most important for the nurse to consider?

A client's spouse has just learned of the client's terminal illness. The spouse is sitting in the corner of the client's room crying, and says to the nurse, "I feel as if I'm already so alone." Which action should the nurse take first?