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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason: Elevated blood pressure is a concern but not as immediately threatening as some other symptoms associated with mitral valve stenosis.

Choice B reason: A rapid, irregular heart rate could indicate atrial fibrillation, which is common in mitral valve stenosis, but it is not as urgent as blood-tinged sputum.

Choice C reason: Swollen feet and ankles suggest fluid retention, which is a concern in mitral valve stenosis but not as immediate as hemoptysis.

Choice D reason: Blood-tinged sputum indicates hemoptysis, which can be a sign of pulmonary edema or other serious complications requiring immediate intervention. This symptom is the most urgent and could signify a potentially life-threatening condition.

A. Promote full diaphragmatic excursion by massaging the back. B. Assist the client to a chair the day after surgery when the condition is stable. C. Note areas of atelectasis on the daily chest x-rays. D. Provide ice or oral liquids when the client passes flatus.

Correct Answer is B

Explanation

Choice A reason: Massaging the back to promote diaphragmatic excursion can be beneficial but is not the most effective intervention compared to early mobilization.

Choice B reason: Assisting the client to sit in a chair encourages lung expansion and sputum clearance, which are crucial for preventing atelectasis and pneumonia.

Choice C reason: Noting areas of atelectasis on chest x-rays is important for monitoring, but it is not an intervention that actively prevents respiratory complications.

Choice D reason: Providing ice or oral liquids when the client passes flatus is related to gastrointestinal recovery, not respiratory complications.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a history of rheumatic fever is diagnosed with mitral valve stenosis. The client has shortness of breath with exertion and fatigue. Which assessment finding warrants immediate intervention by the nurse?

Correct Answer is D

Explanation

After a partial gastrectomy, in addition to frequent position changes, which postoperative intervention is most beneficial for the nurse to perform to prevent respiratory complications?

Correct Answer is B

Explanation

Patient Data Exhibits What can the nurse do to help the parents decrease their anxiety? Select all that apply.

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A client with bladder cancer had surgical placement of a ureter ileostomy (ileal conduit) yesterday. Which postoperative assessment finding should the nurse report to the healthcare provider immediately?