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

Explanation

B. Transferring the initial urine sample into the designated 24-hour urine collection container ensures that the entire collection period is accurately captured. This action helps maintain the integrity of the specimen and allows for an accurate assessment of creatinine clearance.
A. Starting collecting the specimen with the next void is not a correct action to implement. It will result in an incomplete and inaccurate collection of the 24-hour urine specimen. The first sample should be discarded and the collection should start with the second void.
C. Observing the sample for sediment is not a relevant action to implement. It will not affect the collection or the analysis of the 24-hour urine specimen. The nurse should focus on the timing and the volume of the urine collection.
D. Emptying the sample into the 24-hour container is not a correct action to implement. It will contaminate and invalidate the 24-hour urine specimen. The first sample should be discarded and the container should be kept clean and refrigerated.

A. Provide written instructions in the client's native language. B. Have the client demonstrate prescribed wound care. C. Have an interpreter repeat the wound care instructions. D. After each instruction, ask if the client understands.

Correct Answer is B

Explanation

B. Having the client demonstrate wound care allows the nurse to directly observe the client's understanding and competency in performing the necessary procedures. This method provides a practical assessment of the client's ability to carry out self-care tasks at home and allows for immediate feedback and correction if needed.
A. Providing written instructions in the client's native language is an effective way to communicate information, especially for clients with limited English proficiency. However, it may not fully assess the client's understanding of wound care
C. While having an interpreter repeat the wound care instructions can help ensure that the information is accurately communicated to the client, it does not directly assess the client's understanding or ability to perform the tasks.
D. Asking if the client understands after each instruction may not be reliable due to language barriers and the client's potential discomfort in admitting confusion or lack of understanding.

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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

The healthcare provider prescribes a 24-hour urine specimen to be collected for creatinine clearance. The client is eager to go home and tells the nurse that the first sample was put in the urinal 2 hours ago. Which action should the nurse implement?

Correct Answer is B

Explanation

A client who had emergency gallbladder surgery yesterday is getting ready for discharge. The client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client's understanding of self-care at home?

Correct Answer is B

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?

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.

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.)

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 is demonstrating three-point gait crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior indicates that the client understands proper crutch walking?

When assuming care of a client at 1900, the nurse learns in report that a client with a urinary tract infection had an indwelling urinary catheter removed during the previous shift. Which information is most important for the nurse to obtain?

A client with a family history of cardiac disease is seeking information to control risk factors. Which lifestyle modification is most important for the nurse to encourage?

Patient Data Exhibits Drag from the Word Choices to complete the sentence. The nurse determines the client is near death as evidenced by