A client with a traumatic brain injury becomes progressively less responsive to stimuli. The client has a "Do Not Resuscitate" prescription, and the nurse observes that the unlicensed assistive personnel (UAP) has stopped turning the client from side to side as previously scheduled. Which action should the nurse take?
Advise the UAP to resume positioning the client on schedule.
Encourage the UAP to provide comfort care measures only.
Assume total care of the client to monitor neurologic function.
Assign a practical nurse to assist the UAP in turning the client.
The Correct Answer is A
Choice A: Advise the UAP to resume positioning the client on schedule.
Reason: Turning the client from side to side is a critical nursing intervention to prevent complications such as pressure ulcers, pneumonia, and other issues related to immobility. Even though the client has a “Do Not Resuscitate” (DNR) order, it does not mean that comfort and preventive care measures should be stopped. The nurse should advise the UAP to continue with the scheduled positioning to ensure the client’s comfort and prevent further complications.
Choice B: Encourage the UAP to provide comfort care measures only.
Reason: While providing comfort care is essential, it does not mean that other necessary interventions, such as turning the client, should be neglected. Comfort care measures should include turning the client to prevent pressure ulcers and other complications. Therefore, this option is not the best choice as it may lead to neglecting important preventive care.
Choice C: Assume total care of the client to monitor neurologic function.
Reason: Assuming total care of the client is not practical and may not be necessary. The nurse should delegate tasks appropriately and ensure that the UAP is performing their duties correctly. Monitoring neurologic function is important, but it does not require the nurse to take over all aspects of the client’s care.
Choice D: Assign a practical nurse to assist the UAP in turning the client.
Reason: While assigning a practical nurse to assist the UAP might be helpful, it is not necessary if the UAP can resume the scheduled positioning on their own. The nurse should first advise the UAP to continue with the scheduled positioning before considering additional assistance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: While new management's expectations are important, they are not as immediate a concern as job security during restructuring.
Choice B reason: Changes in job descriptions can be a concern, but they are secondary to the more pressing issue of whether employees will retain their jobs.
Choice C reason: Job security is typically the most pressing concern for employees during restructuring, as it directly impacts their livelihood and future with the company.
Choice D reason: Potential changes in employee benefits are important but are generally less immediate than concerns about job security.
Correct Answer is A
Explanation
Choice A reason: The priority is to manage the client's severe pain, which can be achieved through the administration of an IV analgesic. Effective pain management is crucial for postoperative recovery and can prevent complications related to increased pain, such as elevated heart rate and blood pressure.
Choice B reason: While assessing the IV site for patency is important, it is not the most critical intervention when a client is experiencing severe pain.
Choice C reason: Providing a pillow for splinting can help with pain management during movement or coughing but does not directly address the immediate need for pain relief.
Choice D reason: Placing the client in a high-Fowler's position may aid in comfort and breathing but is not the most important intervention for severe pain management.
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