A nurse is caring for a client who has a do-not-resuscitate (DNR) prescription. The client experiences cardiac arrest, and another nurse starts CPR. Which of the following actions should the nurse caring for the client take?
Continue CPR until the provider arrives.
Notify the ethics committee for immediate assistance.
Contact the family to determine what they would like to have done.
Stop the CPR and inform the nurse of the client's advance directives.
The Correct Answer is D
Choice A reason: Continuing CPR until the provider arrives disregards the client’s DNR order. This violates the client’s autonomy and legal rights.
Choice B reason: Notifying the ethics committee is not an immediate action. Ethics committees provide guidance in complex cases but are not involved in urgent bedside decisions.
Choice C reason: Contacting the family to determine what they would like done is inappropriate. The client’s advance directive takes precedence over family wishes.
Choice D reason: Stopping CPR and informing the nurse of the client’s advance directives is correct. A DNR order legally and ethically directs healthcare providers to withhold resuscitation. Respecting this ensures the client’s wishes are honored and prevents unnecessary interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: A change in vocal tone after drinking liquids suggests possible aspiration. Aspiration can worsen pneumonia and lead to respiratory compromise, making this the priority finding to report. Early recognition is critical to prevent further complications.
Choice B reason: Nocturia with incontinence is not directly related to pneumonia and does not pose an immediate threat to the client’s respiratory status.
Choice C reason: A temperature of 38° C is a mild fever and expected with pneumonia. While it should be monitored, it is not the most urgent finding compared to aspiration risk.
Choice D reason: Weight loss of 1.8 kg in a month is concerning but not immediately life-threatening. It does not require urgent reporting compared to aspiration risk.
Correct Answer is A
Explanation
Choice A reason: A positive Babinski reflex beyond infancy is abnormal. Normally, the Babinski reflex disappears by 12 to 18 months of age as the nervous system matures. Persistence of this reflex at 24 months or older indicates possible neurological dysfunction, such as upper motor neuron lesion or developmental delay. This finding should be reported to the provider for further evaluation.
Choice B reason: The Moro reflex is a primitive reflex that disappears by about 4 months of age. Its absence in a toddler is expected and normal. Therefore, this finding does not need to be reported.
Choice C reason: Referring to self by name is an appropriate developmental milestone for toddlers around 24 months. It reflects growing language and self-awareness. This is an expected finding and does not require provider notification.
Choice D reason: Pointing to common objects when asked is a normal developmental milestone for toddlers. It demonstrates receptive language development and cognitive ability. This is expected and does not indicate any abnormality.
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