An older adult client with heart failure has a signed do not resuscitate (DNR) form to put in the medical record. The unlicensed assistive personnel (UAP) reports that the client is not breathing, and the nurse confirms the UAP's findings. Which action should the nurse take next?

Begin cardiopulmonary resuscitation (CPR) and call a code.

Ask the UAP to complete postmortem care.

Notify the family of the client's death.

Report client's status to the healthcare provider.

Answer and Explanation

The Correct Answer is D

D. The healthcare provider is mandated to perform a examination of the client and confirm death before any announcements to the family.
A. The DNR order indicates that the client has chosen not to receive CPR, so beginning resuscitation would go against their wishes.
B. Postmortem care is typically performed after the healthcare provider has pronounced the death
C. notifying the family is usually done after the healthcare provider has been informed and death has been confirmed.

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Correct Answer is ["B","D","E","F","G"]

Explanation

The order is vital signs to be taken every 4 hours

Additional vital signs should be document when the client’s status changes like the diaphoresis seen at 1500 as this could signify a complication.

A. The client will demonstrate ability to change the ostomy bag in two days. B. The client's breath sounds will be auscultated by the nurse every 4 hours. C. The client will adhere to the medication regimen after discharge. D. The client attempts to self-administer insulin but is unable to perform injection.

Correct Answer is C

Explanation

C. Given the client's diagnosis of type 2 diabetes mellitus and the development of hyperglycemia requiring insulin injections after discharge, the priority outcome is for the client to adhere to the medication regimen. Proper management of diabetes through consistent adherence to insulin therapy is crucial for controlling blood sugar levels and preventing complications. Therefore, ensuring the client's understanding of and commitment to the medication regimen is essential for achieving optimal health outcomes.
A. While important for the client's overall postoperative care, it does not directly address the management of hyperglycemia or the need for insulin injections.
B. This outcome statement pertains to respiratory assessment, which is important for monitoring postoperative recovery, particularly after surgery involving the abdomen. However, it does not specifically address the management of hyperglycemia or the need for insulin injections.
D. This outcome statement highlights the client's ability to perform a specific aspect of self-care related to insulin administration. However, it focuses on the client's initial attempts rather than the desired outcome of successfully administering insulin.

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An older adult client with heart failure has a signed do not resuscitate (DNR) form to put in the medical record. The unlicensed assistive personnel (UAP) reports that the client is not breathing, and the nurse confirms the UAP's findings. Which action should the nurse take next?

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Naxlex Comprehensive Predictor Exams

Patient Data Exhibits Review H and P, nurse's notes, flow sheet, laboratory values, orders, and imaging studies. What times should the nurse measure vital signs? Select all that apply.

Correct Answer is ["B","D","E","F","G"]

Explanation

Correct Answer is C

Explanation

The nurse assesses an older adult client's ability to perform activities of daily living (ADLs). When observing the client ambulate. the nurse notes that the client's posture is upright, and the gait is smooth and steady. Which action should the nurse take next?

A client receives a prescription for dextromethorphan 30 mg every 6 to 8 hours PO as needed for cough. The bottle is labeled "Dextromethorphan for Oral Suspension, USP 30 mg per 15 mL." How many tablespoons should the nurse instruct the client to take with each dose? (Enter numerical value only.)

The nurse enters a client's room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?

After completing daily charting at 1400, the nurse realizes that a 0900 occurrence was not entered. Which is the best way for the nurse to enter computer documentation of the 0900 occurrence?

The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action indicates that a UAP understands gloving procedures?

The nurse is assessing a client who is having pain of the right upper abdominal area. To assess the quality of the client's abdominal pain, which approach should the nurse use?

The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform?

A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?