A nurse responds to the room of a client who is recovering from a cardiac arrest where CPR was performed. The client's child is distraught and tells the nurse that their parent has a do-not-resuscitate (DNR) prescription in their medical record. Which of the following actions should the nurse take first?

Report the occurrence to the nursing supervisor,

Complete an incident report stating the facts of the situation.

Verify the DNR prescription is current in the medical record.

Request a meeting with the ethics committee.

Answer and Explanation

The Correct Answer is C

A. Report the occurrence to the nursing supervisor:

While reporting the occurrence is important, verifying the DNR status takes precedence. The nurse needs to gather information and confirm whether the patient has a current DNR order before escalating the issue to a higher authority.

B. Complete an incident report stating the facts of the situation:

Completing an incident report is a part of the process, but it should not be the first action. The immediate concern is to determine if the patient has a valid DNR order. An incident report can be completed later to document the situation and any actions taken.

C. Verify the DNR prescription is current in the medical record.

Verifying the DNR (do-not-resuscitate) prescription is the first and most immediate action the nurse should take. It is crucial to confirm the current status of the DNR order to ensure that the healthcare team is following the patient's wishes. If the DNR is indeed valid and up-to-date, it means the resuscitation efforts, including CPR, were contrary to the patient's expressed wishes.

D. Request a meeting with the ethics committee:

Contacting the ethics committee may be necessary depending on the circumstances, but it is not the first step. Verifying the DNR status is an immediate action that can guide subsequent decisions. If there are ethical concerns or conflicts, involving the ethics committee can be considered after confirming the facts surrounding the DNR order.

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Correct Answer is A

Explanation

A. Log off the computer to attend the client's needs:

Logging off ensures that the client’s health information is protected, maintaining confidentiality and compliance with HIPAA regulations. This prevents unauthorized access to sensitive information when the nurse is away from the computer.

B. Complete the documentation before going to the client's room:

While completing documentation is important, the nurse should prioritize responding to the immediate needs of the client. The nurse can return to complete the documentation afterward.

C. Leave the computer in the hallway:

Leaving the computer unattended in the hallway poses a security risk and compromises the confidentiality of the client's information.

D. Minimize the screen while addressing the client's needs:

Minimizing the screen does not secure the information on the computer. It can still be accessed by others, potentially leading to breaches of client confidentiality.

Correct Answer is ["0.5"]

Explanation

To calculate the volume (mL) that the nurse should administer, you can use the following formula:

Volume (mL) = Dose (mg)/Concentration (mg/mL)

In this case:

Volume =25 mg/50 mg/mL
Volume=0.5mL

Therefore, the nurse should administer 0.5 mL of promethazine for the 25 mg IM dose, rounded to the nearest tenth.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is documenting the care of a client in the computer when she is called to another client's room. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is preparing to administer promethazine 25 mg IM to a client. Available is promethazine 50 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["0.5"]

Explanation

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