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 B

Explanation

A. Acute pain: This diagnosis might be relevant if the patient has pain, but it does not address the main concern of mobility and risk related to recent falls.

B. Risk for injury: This is the most appropriate diagnosis as the patient’s inability to bear weight and recent falls increase their risk of further injury.

C. Activity Intolerance: While the patient may have activity intolerance, the more pressing concern related to their recent falls and inability to bear weight is the risk for injury.

D. Toileting self-care deficit: This diagnosis might be relevant if there were specific issues with toileting, but it is not the most appropriate for the general risk of injury due to recent falls.

A. Gait belt with handles B. Lateral-assist transfer board C. Powered stand-assist aid D. Powered full-body lift

Correct Answer is B

Explanation

A. Gait belt with handles: A gait belt can provide support and stability during transfers, but it is generally used for walking rather than transferring directly from bed to chair.

B. Lateral-assist transfer board: A lateral-assist transfer board can help with moving the patient from bed to chair by sliding, making it appropriate for this transfer scenario.

C. Powered stand-assist aid: A powered stand-assist aid is typically used to help patients who need assistance standing and could be appropriate if the patient requires more support during the transfer.

D. Powered full-body lift: A powered full-body lift is generally used for patients who cannot bear weight at all and would not be necessary for a patient who can bear weight on one leg and use a walker.

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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 developing the plan of care for a patient who is unable to bear weight on the right foot. The patient requires assistance to get out of bed and has recently fallen. Which of the following nursing diagnosis would be most appropriate for this patient?

Correct Answer is B

Explanation

The nurse is preparing to transfer a patient from the bed to a chair next to the bed. The patient has full weight bearing on the right leg and partial weight bearing on the left leg. They use a walker when ambulating. Which of the following assistive devices would be appropriate for the transfer?

Correct Answer is B

Explanation

The nurse is repositioning a patient who has a spinal injury and notes reddened areas on the heels of both feet. The nurse should place the patient in which of the following positions?

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The nurse is obtaining a history from a patient reference activity. Which of the following should be included? Select all that apply.

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