An older woman with end-stage heart disease is hospitalized for severe heart failure. She is alert and requests that no heroic measures be implemented if her breathing stops.
What actions should the nurse take first?
Obtain a do not resuscitate prescription.
Set up a family conference to discuss the client's wishes.
Discuss with the client her meaning of heroic measures.
Consult the palliative care team about the client's care.
The Correct Answer is C
The nurse should first discuss with the client her meaning of heroic measures.
This will help the nurse to understand the client’s wishes and preferences for her care.
Choice A is incorrect because obtaining a do not resuscitate prescription should be done after discussing the client’s wishes and preferences.
Choice B is incorrect because setting up a family conference to discuss the client’s wishes should be done after discussing the client’s wishes and preferences with her.
Choice D is incorrect because consulting the palliative care team about the client’s care should be done after discussing the client’s wishes and preferences with her.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
To exercise the hinge joints, the nurse should instruct the client to bend the arm by flexing the ulna to the humerus.
Hinge joints allow for movement in one direction, like a door hinge. The elbow joint is an example of a hinge joint.
Choice A is not the answer because tapping the feet forwards and backwards exercises the ankle joint, which is not a hinge joint.
Choice C is not the answer because turning the head to the right and left exercises the pivot joint in the neck, which is not a hinge joint.
Choice D is not the answer because extending the arm at the side and rotating in circles exercises the ball-and-socket joint in the shoulder, which is not a hinge joint.
Correct Answer is C
Explanation
When checking the restraints, the most important action for the nurse to take is to assess capillary refill distal to the restraints.
This helps to ensure that the restraints are not too tight and that blood flow to the extremities is not compromised.
Choice B, verifying that the restraints can be quickly released, is important for safety but does not directly address the client’s physical well-being.
Choice D, replacing the nasogastric tube, may also be necessary but is not the most important action in this situation.
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