An older adult male who is in his early 70's is admitted to the emergency department because of a COPD exacerbation. The client is struggling to breathe and the healthcare team is preparing for endotracheal intubation. The spouse's wile, who is 30 years younger than the client, asks the nurse to stop the procedure and provides the nurse a copy of the client's living will. Which action should the nurse take?

Alert the nursing staff of the client's do not resuscitate status.

Notify the healthcare provider of the client's wishes.

Place a certified copy of the living will in the client's record.

Facilitate a family meeting with the palliative care team.

Answer and Explanation

The Correct Answer is B

A. While the nursing staff should be aware of the DNR status, the immediate concern is the client's expressed wishes regarding treatment.

B. Notifying the healthcare provider is essential so that the medical team can respect the client’s wishes, especially in an acute situation where life-saving measures are being discussed.

C. Placing a certified copy of the living will in the record is important, but it should be done after informing the healthcare provider.

D. Facilitating a family meeting may be helpful, but the priority is to communicate the client's wishes to the medical team immediately.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is []

Explanation

Potential Condition
Polycythemia

Tetralogy of Fallot, a congenital heart condition, often leads to decreased oxygenation, which triggers the body to produce more red blood cells to compensate, resulting in polycythemia.

Actions the nurse should take:

Take the child’s vital signs: Monitoring vital signs is essential to assess the child's overall stability and detect any signs of distress or hypoxia.

Ask the child’s parents about the frequency of tet spells: Tet spells (hypercyanotic episodes) are common in children with Tetralogy of Fallot, and understanding their frequency helps assess the child's current condition and plan interventions.

Parameters to monitor:

Oxygen saturation: Monitoring oxygen levels is crucial to determine how well the child is oxygenating and to detect any hypoxia or cyanosis.

Weight: Monitoring weight is important in this child, who is in the lower percentiles for growth, as poor weight gain may indicate the need for nutritional or medical intervention.

A. Explain the purpose of a low bacteria diet. B. Use standard precautions and wear a mask. C. Send wound drainage for culture and sensitivity. D. Monitor the client's white blood cell count. E. Institute contact precautions for staff and visitors.

Correct Answer is ["C","D","E"]

Explanation

A. A low bacteria diet is not typically indicated unless the client is severely immunocompromised, which is not stated in this scenario.

B. Standard precautions are always required, but a mask is not specifically necessary unless there is a respiratory concern; contact precautions are more critical in this context.

C. Sending wound drainage for culture and sensitivity is essential for diagnosing the infection and guiding treatment.

D. Monitoring the white blood cell count is important to assess the client's response to infection and treatment.

E. Instituting contact precautions is crucial to prevent the spread of VRE to other patients and healthcare workers.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

A client with purulent drainage from an abdominal surgical incision is admitted with a possible vancomycin-resistant enterococci (VRE) infection. Which nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

Correct Answer is ["C","D","E"]

Explanation

The nurse is assessing a 4-year-old client with eczema. The child's skin is dry and scaly, and the parent reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated for care of this child?

The healthcare provider prescribes the antibiotic cefdinir 300 mg PO every 12 hours for a client with a postoperative wound infection. Which foods should the nurse encourage this client to eat?

The healthcare provider prescribes a low-fiber diet for a client with ulcerative colitis. Which food selection indicates to the nurse that the client understands the prescribed diet?

A client admitted with pneumonia and on bedrest has not had the strength to perform self care. Which assessment finding provides the nurse with the earliest indication that the client is developing a pressure injury?

Exhibits The nurse discusses the need to balance energy intake and output to maintain weight. Click to indicate whether the following actions would be effective or ineffective for this client to achieve energy balance. Each row must have one option selected.

The nurse is performing tracheostomy care for a client when a code blue is called for another client on the unit who experiences a cardiopulmonary arrest. Which action should the nurse take?

A client with chronic kidney disease (CKD) has an arteriovenous (AV) fistula in the left forearm. Which observation by the nurse indicates that the fistula is patent?

The nurse observes that a client with ascites is dyspneic. Which action should the nurse implement first?