A nurse is speaking with the partner of a client who is unconscious and has a do-not-resuscitate (DNR) order in place. The partner requests that CPR be performed if necessary. Which of the following responses should the nurse make?

"Let's discuss other areas of your partner's care."

"I understand how you feel because I recently lost a family member myself."

"It must be very difficult for you to accept your partner's wishes."

"You should call your partner's provider to change the DNR order."

Answer and Explanation

The Correct Answer is C

a)   This response may seem dismissive of the partner’s immediate concern about the DNR order and does not directly address their request.
b)   While this response attempts to establish a connection through shared experience, it may shift the focus away from the partner's feelings and can come off as self-centered. It may also invalidate the partner's unique experience of loss.
c)   This response acknowledges the emotional distress and difficulty the partner is experiencing while validating their feelings. It shows empathy and understanding, which can help build rapport and encourage further communication about the situation.

d) This response is inappropriate because it does not respect the existing DNR order and could create confusion or frustration for the partner. Additionally, changing a DNR order requires specific processes and discussions with the healthcare team.

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Correct Answer is D

Explanation

A. Palpate the abdomen: Palpating the abdomen before auscultating bowel sounds could potentially alter the findings by stimulating peristalsis or causing discomfort in the client, particularly in cases of appendicitis or other acute abdominal conditions.

B. Administer an antiemetic:A thorough assessment, including auscultation of bowel sounds, is needed first to rule out conditions like a bowel obstruction or paralytic ileus where antiemetics may be contraindicated.

C. Offer pain medication:Pain medication can mask symptoms and interfere with the nurse's or physician's ability to accurately assess the underlying cause of the client's symptoms, such as appendicitis.

D. Auscultate bowel sounds:Auscultating bowel sounds is the first action the nurse should take because it is a non-invasive assessment that can provide critical information. It helps determine if bowel sounds are present, hyperactive, hypoactive, or absent, which can guide further interventions and diagnostic steps.

A. Decreased judgment B. Decreased activity C. Increased reﬂexes D. Increased auditory alertness

Correct Answer is A

Explanation

Decreased judgment is a common sign of sleep deprivation. When a person is sleep deprived, their cognitive function can be impaired, leading to difficulty making decisions and exercising good judgment.

Options b, c, and d are not necessarily indicative of sleep deprivation. Decreased activity can be a sign of many diﬀerent conditions, including fatigue or depression. Increased reﬂexes and increased auditory alertness are not commonly associated with sleep deprivation.

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A nurse is speaking with the partner of a client who is unconscious and has a do-not-resuscitate (DNR) order in place. The partner requests that CPR be performed if necessary. Which of the following responses should the nurse make?

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Correct Answer is A

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