The nurse is caring for a client diagnosed with cancer. The client has discussed having a DNR order written but is undecided. The nurse enters the client's room with their domestic partner sitting at the client's bedside. The nurse assesses that the client is not breathing spontaneously & unresponsive. What is the first appropriate action by the nurse?
Assist the significant other out of the room.
Activate the facility's response system for a code
Inform the physician that the client is apneic.
Ask the client's partner to make a DNR decision immediately.
The Correct Answer is B
B. Activating a code blue or the facility's emergency response system will bring immediate assistance and resources to the client's bedside. This is crucial to initiate prompt resuscitative measures if indicated and to involve additional healthcare providers in the management of the emergency.
A. While it might be appropriate in some situations to provide privacy or support to the partner, in this urgent scenario where the client is unresponsive and not breathing, the priority should be immediate assessment and intervention for the client's condition.
C. While notifying the physician is important, especially to inform them of the client's condition and potentially discuss the DNR status, it is not the most immediate action in this urgent situation where the client is unresponsive and not breathing. Direct intervention and assessment are needed first.
D. Asking the partner to make a DNR decision immediately is not appropriate as the first action in this scenario. It is crucial to focus first on the client's immediate needs for assessment and potentially resuscitative measures if indicated. The discussion about the DNR order should occur in a timely manner but is secondary to addressing the client's current medical emergency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Such an assessment helps in determining the level of assistance the client will need and ensures the safety of both the client and the nurse.
A. Helping the client to sit at the edge of the bed allows them to acclimate to being upright, assess their readiness to stand, and ensures their safety before attempting to walk. However, it is not the priority.
C. After assisting the client to a sitting position at the edge of the bed and assessing their readiness, the nurse can proceed to help the client into a standing position. However, it is not the priority.
D. This option may be necessary if the client requires two-person assistance due to their condition, mobility status, or safety concerns. However, asking for assistance typically comes after assessing the client's readiness and ensuring they are positioned correctly for ambulation.
Correct Answer is D
Explanation
D. Processed foods, including canned soups, snacks, and pre-packaged meals, are major sources of dietary sodium. By avoiding processed foods, the client can significantly reduce their sodium intake and better adhere to a low-sodium diet.
A. While organic vegetables may be a healthy choice for other reasons (such as reducing pesticide exposure), canned vegetables, whether organic or not, often contain added sodium for preservation. Therefore, selecting canned vegetables, even if organic, may not align with the goal of reducing sodium intake.
B. This statement suggests an understanding of choosing lower-sodium options for sandwiches. Lean deli meats, such as turkey or chicken breast, typically contain less sodium compared to processed or cured meats like salami or bologna. Opting for lean deli meats supports the client's effort to reduce sodium intake as part of a low-sodium diet.
C. This statement indicates a misunderstanding of a low-sodium diet. Smoked meats, such as smoked ham or bacon, are often high in sodium due to the curing and smoking process. Including smoked meat products in the diet would likely increase sodium intake, which contradicts the goal of reducing sodium.
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