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 B

Explanation

A. While connecting the client with others may provide support, it does not directly address the client’s frustrations or concerns about their therapy.
B. Asking the provider to speak with the client directly can facilitate communication about their concerns and may help address their frustrations regarding the plan of care.
C. Threatening the client with consequences for leaving is not appropriate and may increase their frustration and disengagement from care.
D. It is important to respect the client’s autonomy and right to leave, so informing them they cannot leave is not appropriate or legal without proper discharge procedures being followed.

A. A client who has type 2 diabetes mellitus needs assistance counting the carbohydrates in her meal. B. A client who has a new tracheostomy is experiencing coughing episodes. C. A client who has a BMI of 17 refuses his dinner tray. D. A client awaiting discharge needs to demonstrate colostomy care before leaving.

Correct Answer is B

Explanation

A. Assisting a client with counting carbohydrates is important for managing diabetes, but it is not an urgent need that must be addressed immediately.
B. A client with a new tracheostomy who is experiencing coughing episodes may indicate a risk for airway obstruction or other complications, making this the most urgent situation that requires immediate intervention.
C. A client with a BMI of 17 who refuses dinner could be concerning for nutritional status, but it is not as critical as addressing potential airway issues with the tracheostomy client.
D. While demonstrating colostomy care is essential for discharge readiness, it can wait until more urgent needs are addressed. Ensuring the client with a tracheostomy is stable is the priority.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

A nurse is reviewing client information following the evening change-of-shift report. Which of the following client needs should the nurse address first?

Correct Answer is B

Explanation

A nurse reviewing prescriptions for a client who has a gastrointestinal bleed is determining the need for special informed consent. Which of the following prescriptions should the nurse identify as covered under the client's general consent for treatment?

A nurse is admitting a client for an elective surgical procedure. During the client interview, one of the client's family members faints. Which of the following actions should the nurse take first?

A nurse enters a client's room and sees smoke coming from a wall outlet. After removing the client from the room, which of the following actions should the nurse take next?

A nurse notices that a client's health information is visible on an unattended computer screen at the nurses' station. Which of the following actions should the nurse take first?

A nurse is asked by the unit manager to provide input for the performance appraisal of an assistive personnel (AP). Which of the following actions should the nurse take?

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?

A nurse is caring for a 16-year-old client who was in a motor-vehicle crash and needs surgical intervention immediately. The staff cannot reach either of the client's parents. The nurse should identify that which of the following is true about obtaining consent?