A nurse is caring for a client who has gone into cardiac arrest. The client's chart indicates refusal of life-sustaining measures in a living will signed 10 years ago, but a do-not-resuscitate (DNR) prescription has not been written by the provider. Which of the following actions by the nurse is appropriate?

Contact the provider for instructions regarding a DNR.

Consult with the client's family regarding resuscitation efforts.

Comply with the living will and let the client expire naturally.

Call a code because a DNR prescription has not been written.

Answer and Explanation

The Correct Answer is D

A. Contacting the provider for instructions could delay immediate resuscitative efforts, which are required in the absence of a DNR order.
B. Consulting with the client’s family may not be effective in an emergency, as the living will is a legal document, and family members cannot override it without a DNR order.
C. Complying with the living will and letting the client expire naturally would be inappropriate without a formal DNR order in place.
D. Calling a code is the correct action because, legally, resuscitative efforts must be initiated in the absence of a written DNR order from the provider, despite the existence of a living will.

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Correct Answer is D

Explanation

A. While paranoia in a client with dementia can be concerning, it is not immediately life-threatening and may require additional support or medication adjustments.
B. Itching after receiving a dose of cefaclor may indicate an allergic reaction, but further assessment would be needed to determine the severity.
C. A weight gain of 1 kg (2.2 lb) in a client with heart failure should be monitored, but it is not an immediate concern unless accompanied by other symptoms of fluid overload.
D. The progression of a pressure ulcer from stage II to stage III indicates a worsening condition that requires urgent intervention to prevent further complications and potential infection, making it the highest priority to report.

A. Investigate which home care services are covered by the client's insurance provider. B. Develop a nutritional teaching plan for a high-protein diet for wound healing. C. Create a collaborative plan of care to guide the actions of the health care team. D. Collect data about the level of assistance that the client requires to perform self-care.

Correct Answer is D

Explanation

A. Investigating home care services covered by insurance is not the primary focus of a nurse preparing for an interprofessional meeting.
B. Developing a nutritional teaching plan, while beneficial, is more specific to nursing care and may not require input from the entire interprofessional team.
C. Creating a collaborative plan of care is a goal of the meeting itself rather than an individual preparation task.
D. Collecting data on the client’s required assistance level provides valuable input on the client’s current functional status, enabling a more comprehensive team discussion and planning for appropriate interventions.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is caring for a group of clients. The nurse should recognize that which of the following information is the highest priority to report to the nursing supervisor?

Correct Answer is D

Explanation

A nurse at a rehabilitation facility is planning to attend an interprofessional team meeting to discuss a client who is recovering from abdominal surgery. Which of the following actions should the nurse take to prepare for the meeting?

Correct Answer is D

Explanation

A nurse is collecting data from a client who is 1 day postoperative following a total hip arthroplasty. Which of the following findings is the priority for the nurse to report to the provider?

A nurse is assisting with the plan of care for a client. Which of the following activities should the nurse include in the implementation phase of the nursing process?

A nurse is assisting in the review of infection control precautions implemented by staff in a facility. Exhibits Select 2 client situations that require follow-up by the infection control nurse.

A nurse is caring for a client who states, "I am leaving this hospital because I'm frustrated with my therapy." Which of the following actions should the nurse take?

A nurse is reinforcing teaching with a newly licensed nurse about client confidentiality. Which of the following information should the nurse include?

A nurse is reviewing his client care assignments after receiving change-of-shift report. The nurse should notify the charge nurse that which of the following tasks should be reassigned to an RN?

A nurse is caring for a client who reports his medication was not given during the night shift for the past 3 nights. The medication administration record indicates the medication was given. Which of the following actions by the nurse is appropriate?

A nurse is assisting with the discharge of a client who is postoperative following a total knee arthroplasty. The client lives alone and does not have any friends or relatives who live close by. Which of the following actions should the nurse plan to take?