A client who is terminally ill has an advance directive that stipulates no resuscitative measures are to be taken. The client's death is imminent and the family is in the client's room. The client is currently exhibiting Cheyne-Stokes respirations and has a blood pressure of 60/30 mm Hg. Which is the priority nursing action?

Allow privacy for the family and client to express their feelings to one another.

Apply an automatic blood pressure cuff and take readings every 15 minutes.

Teach the client's family how to use an oral suction device to clear the airway.

Elevate the head of the client's bed and apply oxygen using a face mask.

Answer and Explanation

The Correct Answer is A

A.   Allowing privacy for the family and client is a compassionate and appropriate action, especially as the client's death is imminent. This respects the client's wishes and provides a supportive environment for the family to process their emotions and say their goodbyes.
B.   Continuously measuring blood pressure in this scenario is less appropriate because the client is in the final stages of life and their focus should be on comfort rather than monitoring vital signs. Frequent blood pressure measurements may be distressing for the family and do not align with the goals of end- of-life care, which prioritize comfort and dignity.
C.   Teaching the family to use an oral suction device is not appropriate at this stage because the client is actively dying, and such interventions are not typically useful or necessary in end-of-life care. The focus should be on providing comfort rather than invasive procedures or teaching new skills to family members.
D.   Applying oxygen and elevating the head of the bed can be appropriate interventions for clients experiencing respiratory distress; however, this may conflict with the advance directive if the directive explicitly states no resuscitative measures

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Correct Answer is B

Explanation

A. Document in the EHR: While documenting the event in the electronic health record is important, it's not sufficient to address the medication error. An incident report provides a more comprehensive and structured approach to documenting and investigating the event.
B. When a medication error occurs, it's crucial to document the event through an incident report. This helps to identify the root cause of the error, prevent similar occurrences in the future, and ensure patient safety. An incident report should include a detailed description of the event, the actions taken, and any potential contributing factors.
C. While informing the next shift is important for continuity of care, it's not the most immediate action needed to address the medication error. Completing an incident report is a higher priority.
D. Notifying the healthcare provider is important, but it should be done in conjunction with completing an incident report. The incident report provides a detailed record of the event, which can be shared with the healthcare provider for further review and investigation.

A. Manually ventilate using a bag valve mask apparatus. B. Determine if client wishes have changed. C. Report client's status to the healthcare provider. D. Administer oxygen via a nasal cannula.

Correct Answer is D

Explanation

A. Using a bag valve mask (BVM) to manually ventilate the client would be considered an extraordinary measure, which conflicts with the client's living will stating no extraordinary measures should be taken.
B. While it's essential to ensure that the client's current wishes are respected, the client is likely unable to communicate effectively due to their condition. If the client were able to express their wishes at this stage, it might be important to confirm, but given the client's living will and the established DNR order, the primary focus should be on adhering to these documents.
C. Reporting the client's status to the healthcare provider is important to ensure that the provider is informed about the client’s current condition and can offer guidance or make necessary adjustments in the care plan. However, if the healthcare provider is already aware of the client's living will and DNR order, this step may be secondary to following the existing orders.
D. Administering supplemental oxygen via a nasal cannula is a palliative measure that can provide comfort without being considered an extraordinary measure. It aligns with the goal of providing symptom relief and comfort care rather than resuscitation or life-extending interventions.

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Explanation

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Explanation

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