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 B

Explanation

If a nurse hangs a bag of dextrose 5% in water, 1,000 mL at 0800 to run at 125 mL/hr and notices that the client's IV bag is empty at 1200, the first intervention the nurse should take is to assess the client's vital signs. This will help the nurse determine if the client is experiencing any adverse eﬀects from the rapid infusion of ﬂuids.

Option a is incorrect because notifying the primary care provider is important but not the first intervention.

Option c is incorrect because calculating the infused volume is important but not the first intervention.

Option d is incorrect because completing an incident report is important but not the first intervention.

A. Complete the bath even if the client is in distress. B. Allow the client to select the temperature of the bath water. C. Give detailed instructions for the client to follow. D. Use distractions when bathing the client.

Correct Answer is D

Explanation

A. Complete the bath even if the client is in distress. – Forcing the bath can increase agitation and damage trust. If the client becomes distressed, pause, reassure, and try again later.

B. Allow the client to select the temperature of the bath water. – Clients with dementia may have impaired sensory perception, increasing the risk of burns or discomfort. The nurse should check the water temperature to ensure safety.

C. Give detailed instructions for the client to follow. – Clients with dementia may struggle to process multiple steps, leading to frustration. Instead, use simple, one-step instructions and gentle guidance.

D. Use distractions when bathing the client.Clients with dementia may experience anxiety, agitation, or distress during bathing. Using distractions, such as playing soothing music, talking about familiar topics, or providing a comforting touch, can help make the experience less stressful and more cooperative.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse hangs a bag of dextrose 5% in water, 1,000 mL at 0800 to run at 125 mL/hr. At 1200, the nurse notices that the client's IV bag is empty. Which of the following interventions should the nurse take first?

Correct Answer is B

Explanation

A nurse is preparing to bathe a client who has dementia. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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A nurse is planning to provide discharge instructions to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take?