The nurse is caring for a client with a terminal illness who has become pulseless. The code status for the client is unknown to the nurse and a hospital emergency response is called. Which of the following actions should the nurse take?

Verify the client's code status.

Begin cardiopulmonary resuscitation.

Provide comfort measures until family arrives.

Initiate a slow code response.

Answer and Explanation

The Correct Answer is B

A. Verify the client's code status: Although verifying code status is important, it may delay necessary emergency interventions. In an urgent situation where the code status is unknown, immediate action is required.

B. Begin cardiopulmonary resuscitation (CPR). When a client is pulseless and the code status is unknown, the priority is to start CPR while emergency services are called. This ensures that the client receives potentially life-saving care promptly.

C. Provide comfort measures until family arrives. This is not appropriate if the client is pulseless and immediate resuscitation efforts are needed.

D. Initiate a slow code response. A slow code is not appropriate in an emergency situation where the patient requires immediate resuscitation.

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Correct Answer is D

Explanation

A. The client with breast cancer who had a mastectomy. This client is facing a significant life change and physical alteration that may lead to psychosocial stressors such as body image issues and emotional distress.

B. The client with chronic obstructive pulmonary disease who requires oxygen therapy. Although this condition is challenging, the primary stressors are often physical and related to the management of the disease rather than psychosocial stressors.

C. The client with colon cancer who has a colostomy. A colostomy can affect body image and self-esteem, potentially leading to psychosocial stressors such as anxiety or social isolation.

D. The client with a left upper arm fracture who was a victim of a crime. The fracture and the trauma of being a crime victim are significant psychosocial stressors. The emotional and psychological impact of the crime can affect the client’s overall mental health.

A. Clean skin using a side to side motion. B. Keep skin pinched while injecting medication. C. Apply firm pressure to the injection site. D. Insert the needle at a 45 or 90-degree angle.

Correct Answer is ["B","D"]

Explanation

A. Clean skin using a side to side motion. The skin should be cleaned in a circular motion from the center outward to reduce the risk of infection.

B. Keep skin pinched while injecting medication. Pinching the skin helps create a small "pocket" for the injection, making it easier to administer the medication subcutaneously.

C. Apply firm pressure to the injection site. Applying firm pressure is not recommended immediately after the injection as it can cause discomfort and does not affect absorption. Gentle pressure is usually recommended.

D. Insert the needle at a 45 or 90-degree angle. For subcutaneous injections, a 45-degree angle is often recommended for thinner individuals, while a 90-degree angle is appropriate for those with more tissue.

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The nurse is caring for a client with a terminal illness who has become pulseless. The code status for the client is unknown to the nurse and a hospital emergency response is called. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a group of clients for psychosocial stressors. Which of the following client's should the nurse identify as having this type of stressor?

Correct Answer is D

Explanation

The nurse is administering a subcutaneous injection to a client. Which of the following actions should the nurse take?

Correct Answer is ["B","D"]

Explanation

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