A nurse is caring for a client who has an end-stage lung disease. The client requests not to be resuscitated if their condition worsens. Which of the following actions should the nurse take?
Explain to the client what it means to change their code status.
Place a sign with “Do Not Resuscitate” outside the client’s room.
Obtain consent from the family to change the plan of care.
Document the client’s request in the medical record.
Correct Answer : A,D
Choice A reason: Explaining the implications of a Do Not Resuscitate (DNR) status ensures the client understands that no CPR or intubation will occur if their condition deteriorates. This supports informed consent and autonomy, clarifying the scope of DNR to prevent misunderstandings. It respects the client’s decision-making capacity, ensuring their wishes align with end-of-life care preferences.
Choice B reason: Placing a “Do Not Resuscitate” sign outside the room breaches confidentiality under HIPAA, risking unauthorized disclosure of sensitive information. DNR status is communicated via medical records or wristbands. This action is inappropriate, as it does not contribute to implementing the client’s wishes and violates privacy standards, making it an incorrect response.
Choice C reason: Obtaining family consent is unnecessary for a competent client’s DNR request, as autonomy rests with the client. If decisionally capable, their wishes override family input. The nurse’s role is to support the client’s decision, not seek family approval, unless the client is incapacitated, which is not indicated, making this action inappropriate.
Choice D reason: Documenting the DNR request in the medical record ensures the care team follows the client’s wishes, preventing unwanted interventions. Accurate documentation communicates code status, supports legal and ethical standards, and ensures continuity of care. This is critical for aligning treatment with the client’s end-of-life preferences, making it a necessary action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Bleeding time assesses platelet function, not warfarin’s anticoagulant effect. Warfarin inhibits vitamin K-dependent clotting factors, unrelated to platelets. Monitoring bleeding time does not reflect therapeutic anticoagulation levels, making it irrelevant for adjusting warfarin doses to prevent thrombosis or bleeding.
Choice B reason: Factor VIII, deficient in hemophilia A, is not affected by warfarin, which targets vitamin K-dependent factors (II, VII, IX, X). Measuring Factor VIII does not indicate warfarin’s efficacy, as it is unrelated to the drug’s mechanism, making it unsuitable for dose monitoring.
Choice C reason: aPTT monitors heparin’s effect on the intrinsic clotting pathway, not warfarin’s action on vitamin K-dependent factors. Warfarin requires INR for therapeutic monitoring, as aPTT is insensitive to its effects, making it inappropriate for assessing warfarin’s anticoagulation range in patients.
Choice D reason: INR standardizes prothrombin time, measuring warfarin’s effect on vitamin K-dependent clotting factors. It ensures therapeutic anticoagulation (e.g., INR 2-3), preventing thrombosis or bleeding. INR is the gold standard for warfarin monitoring, guiding dose adjustments for safe and effective therapy.
Correct Answer is D
Explanation
Choice A reason: A client with a sealed radiation implant requires strict precautions and monitoring to prevent radiation exposure to others. Early discharge is unsafe due to ongoing treatment needs, so this client is not suitable, making this incorrect.
Choice B reason: A COPD client with a respiratory rate of 24 breaths/min indicates potential instability, requiring monitoring for exacerbation. Early discharge risks decompensation without ensured stability, so this client is not appropriate, making this incorrect.
Choice C reason: A client receiving heparin for DVT needs continuous anticoagulation and monitoring to prevent embolism. Discharging early risks clotting complications, so this client requires ongoing hospital care, making this incorrect for early discharge.
Choice D reason: A client 1 day post-cholecystectomy, if stable, is often ready for discharge, as this surgery is routine with quick recovery. Freeing this bed supports disaster response, aligning with triage principles, making this the correct choice.
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