A client on the cardiac telemetry unit unexpectedly begins manifesting ventricular fibrillation and 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.

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

Check the client's arm for a "Do Not Resuscitate" (DNR) bracelet.

Explain that living wills cannot be followed by emergency personnel.

Answer and Explanation

The Correct Answer is B

A.   While scheduling a client and family conference may be necessary to discuss the plan of care, the immediate concern is to determine the type of advance directive the client has and whether it includes preferences regarding resuscitation.
B.   This is the most appropriate action because it addresses the family member's concern and ensures that the client's wishes regarding resuscitation are understood and followed.
C.   While checking for a DNR bracelet is important, it does not address the family member's question about why the code was called despite the client having a living will.
D.   This statement is incorrect. Living wills can guide decision-making regarding end-of-life care, including resuscitation, depending on the legal requirements and documentation in place.

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Free Nursing Study Resources

Correct Answer is C

Explanation

Activity restriction does not directly decrease abdominal pain. Pain management in Crohn’s disease is typically achieved through medications, dietary adjustments, and addressing inflammation.

B. While activity restriction may indirectly help decrease abdominal pain by reducing inflammation and promoting healing, it is not the primary purpose of the restriction.
C.The primary goal of activity restriction in Crohn's disease is to reduce intestinal activity. By limiting physical exertion, the intestines are less stimulated, which can help reduce inflammation and give the digestive system a chance to rest and recover.
D. While activity restriction may help control diarrhea episodes by reducing physical stress on the intestines, the primary purpose is to promote healing and reduce inflammation. Control of diarrhea may be achieved through other interventions such as dietary modifications and
medication management.

A. Left 5th intercostal space midclavicular line B. Right carotid area C. Over the brachial artery D. Over the sternum

Correct Answer is C

Explanation

A. Left 5th intercostal space midclavicular line: Palpating the left 5th intercostal space midclavicular line is not appropriate for assessing pulse in an unresponsive infant. This location is typically used for cardiac auscultation and not for pulse assessment.
B. Right carotid area: Palpating the carotid artery is not recommended in infants due to the risk of causing injury to the delicate structures of the neck, including the
airway and blood vessels.

C. Over the brachial artery: The brachial artery is the preferred site for assessing pulse in infants. It is located in the inner aspect of the upper arm and can be easily palpated. In an unresponsive infant, the brachial pulse should be assessed before
initiating CPR.

D. Over the sternum: Palpating over the sternum is not an appropriate site for pulse assessment in infants. The sternum is a bone and does not contain any major arteries suitable for pulse palpation.

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Naxlex Comprehensive Predictor Exams

Restricted activity is prescribed for a client with Crohn's disease. The nurse should explain that the primary purpose of the activity restriction is to obtain which outcome?

Correct Answer is C

Explanation

An infant is unresponsive and gasping for breath. Prior to starting CPR, which site should the nurse palpate for a pulse?

Correct Answer is C

Explanation

Exhibits To start the client on oxygen as ordered, what item(s) should the nurse collect from the supply room? Select all that apply.

The nurse is collecting a heelstick blood specimen for a neonatal screen, which includes thyroxine (T4) and thyroid stimulating hormone (TSH) levels, prior to the discharge of a 2-day- old client. When the parents ask why these tests are being conducted, which explanation should the nurse provide?

In formulating the nursing care plan for a client diagnosed with Parkinson's disease, which nursing problem has the highest priority?

Exhibits Based on the client's status at 1400, the nurse should plan to do which of the following? Select all that apply.

The nurse is providing teaching to a client admitted with a blood glucose level of 580 mg/dL about preventing complications related to diabetes mellitus. Which information reported by the client indicates understanding?

While the nurse is conducting an admission assessment of a female client with bipolar disorder, the client suddenly begins to take off her clothes and throw them about the room. Which action should the nurse take first?