A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement)
The client's need for pain medication should be determined.
The nurse manager should be updated on the client's status
The client's status should be conveyed to the chaplain.
The impending signs of death should be documented
The Correct Answer is A
A. Determining the client's need for pain medication is a priority to ensure comfort and manage symptoms as the client approaches end of life.
B. Updating the nurse manager on the client's status is important, but it is not the priority action in terms of direct client care.
C. Conveying the client's status to the chaplain may be part of holistic care, but the immediate physical needs of the client take precedence.
D. Documenting the impending signs of death is essential for medical records, but addressing the client's comfort needs is the priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Determining the patient's need for pain medication is a priority to ensure the patient's comfort during the end-of-life care process. Pain management is a critical aspect of palliative care and should be addressed promptly.
B. Updating the nurse manager on the patient's status is important but is not the immediate priority. The nurse manager's awareness does not directly impact the patient's comfort or care at the moment of impending death.
C. Conveying the patient's status to the chaplain may be part of the holistic care approach and can provide spiritual support to the patient and family, but it is not the first priority in terms of the patient's immediate physical needs.
D. Documenting the impending signs of death is essential for legal and medical records; however, it is secondary to addressing the patient's immediate needs, such as pain relief.
Correct Answer is D
Explanation
A. Initiate seizure precautions: Dopamine administration does not typically require seizure
precautions. The focus should be on monitoring for adverse effects related to blood pressure and urinary output.
B. Monitor serum potassium frequently: While electrolyte imbalances can occur with dopamine administration, the priority is to monitor urinary output as dopamine affects renal perfusion and urine output.
C. Assess pupillary response to light hourly: Monitoring pupillary response is important in some situations, but it's not the primary concern with dopamine administration.
D. Measure urinary output every hour: Correct! Dopamine is administered to improve renal perfusion and increase urine output in hypotensive patients. Monitoring urinary output every
hour is essential to assess the effectiveness of dopamine therapy and detect any signs of renal dysfunction or worsening hypotension.
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