A client on the cardiac telemetry unit suddenly starts showing signs of ventricular fibrillation. The advanced cardiac life support (ACLS) team defibrillates the client, restoring a normal sinus rhythm. Later in the day, a family member Questions why the code was called, telling the nurse that the client has a living will.
How should the nurse respond?

Schedule a client and family conference to review the plan of care.

Explain that living wills cannot be followed by emergency personnel.

Check the client’s arm for a “Do Not Resuscitate” (DNR) bracelet.

Seek clarification of the type of advance directive the client has.

Answer and Explanation

The Correct Answer is D

Choice D rationale
Seeking clarification of the type of advance directive the client has is the most appropriate response. A living will typically outlines a person’s wishes for end-of-life care, but it may not specifically address emergency situations like cardiac arrest.

Choice A rationale
Scheduling a client and family conference to review the plan of care may be helpful, but it is not the immediate priority. The nurse first needs to understand the client’s wishes as outlined in their advance directive.

Choice B rationale
Explaining that living wills cannot be followed by emergency personnel is not entirely accurate. While it’s true that emergency personnel initiating resuscitative measures may not have immediate access to a person’s living will, in a hospital setting, a person’s known wishes should be respected as much as possible.

Choice C rationale

Checking the client’s arm for a “Do Not Resuscitate” (DNR) bracelet is not the most appropriate response. While some people may choose to wear such a bracelet, not all do. Furthermore, a DNR order is just one type of advance directive, and it’s important to clarify what specific directives the client has in place.

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Correct Answer is C

Explanation

Choice A rationale
While the sensitivity of genetic markers can influence the choice of treatment, it is not the primary pathophysiological process involved in BRCA1 and BRCA2 genetic testing. The main purpose of these tests is to identify genetic mutations that increase the risk of developing certain types of cancer.
Choice B rationale
BRCA1 and BRCA2 do play a role in protecting mature, functioning breast and ovarian cells. However, this is not the primary reason for conducting BRCA1 and BRCA2 genetic testing. The main purpose of these tests is to identify mutations that increase cancer risk.
Choice C rationale

This is the correct answer. Mutations in BRCA1 or BRCA2 can significantly increase a person’s risk for developing breast and ovarian cancer. Therefore, identifying these mutations through genetic testing can help determine a person’s cancer risk.
Choice D rationale
While inherited mutations in BRCA1 and BRCA2 can influence the prognosis of breast cancer, the primary purpose of BRCA1 and BRCA2 genetic testing is to identify mutations that increase cancer risk, not to determine prognosis.

A. Initiate two large-bore IV catheters and review the inclusion criteria for IV fibrinolytic therapy. B. Begin continuous observation for transient episodes of neurological dysfunction. C. Elevate the head of the bed to 30 degrees, keeping the head and neck in neutral alignment. D. Administer aspirin to prevent further clot formation and platelet aggregation.

Correct Answer is A

Explanation

Choice A rationale
The symptoms described - right-sided numbness and weakness in the arm and leg, along with a distinct droop on the right side of the face - are indicative of a stroke. Immediate medical intervention is crucial in such cases. Initiating two large-bore IV catheters would allow for rapid administration of necessary medications and fluids. Reviewing the inclusion criteria for IV fibrinolytic therapy is also important, as this type of therapy can help dissolve the clot causing the stroke and restore blood flow to the brain.

Choice B rationale
While continuous observation for transient episodes of neurological dysfunction is important in the care of a patient with suspected stroke, it is not the first course of action. Immediate medical intervention to treat the stroke is the priority.
Choice C rationale
Elevating the head of the bed to 30 degrees can help reduce intracranial pressure in a patient with a stroke. However, this is not the first course of action. Immediate medical intervention to treat the stroke is the priority.
Choice D rationale
Administering aspirin can help prevent further clot formation and platelet aggregation in patients with certain types of stroke. However, aspirin is not typically the first line treatment in the acute phase of a stroke, especially when the type of stroke (ischemic or hemorrhagic) has not yet been determined.

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Naxlex Comprehensive Predictor Exams

The nurse is preparing a client with breast cancer for BRCA1 and BRCA2 genetic testing. Which pathophysiological process should the nurse use to support client teaching?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

Before inserting an indwelling urinary catheter, which information about the patient is most important for the nurse to obtain?

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