A graduate nurse enters a client's room and finds the client unresponsive, not breathing, and without a carotid pulse. The graduate nurse is aware that the client has mentioned that he does not wish to be resuscitated, but there is no DNR order on the client's chart. What is the nurse's best action?

Respect the client's wishes and avoid calling a code.

Initiate a slow-code hoping the client does not make it until the physician arrives.

Call a code and begin resuscitating the client.

Consult with the charge nurse or nurse manager before calling the code.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C. Call a code and begin resuscitating the client.

In a situation where a client is unresponsive, not breathing, and without a carotid pulse, the priority is to initiate emergency resuscitation measures. The nurse should call a code and begin resuscitating the client immediately, regardless of any prior conversations or wishes that the client may have expressed. If there is no DNR order on the client's chart, it is assumed that the client would want to be resuscitated in such an emergency situation. It is not appropriate for the nurse to make a decision based on a conversation that may or may not have taken place in the past without documentation or a valid DNR order. It is important to act quickly and follow emergency protocols to provide the best chance of survival for the client. After the resuscitation measures have been initiated, the healthcare team can reassess the situation and make decisions based on the client's condition and wishes, if known.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["A","B","C","D","E"]

Explanation

The correct answer is choices A, B, C, D, and E.

Hypoxia occurs when there is inadequate oxygen supply to the body's tissues. Signs of hypoxia can vary depending on the severity of the condition. The following signs can indicate hypoxia:

Increased respiratory rate - Hypoxia can cause an increased respiratory rate as the body tries to increase oxygen levels in the blood.
Confusion - Hypoxia can affect cognitive function, leading to confusion.
Cyanosis - Hypoxia can cause a blue or purple discoloration of the skin, lips, or nail beds due to the lack of oxygen.
Restlessness - Hypoxia can cause restlessness or agitation.
Dyspnea - Hypoxia can cause difficulty breathing, also known as dyspnea.
Bradycardia - Bradycardia, or a slow heart rate, is not typically a direct sign of hypoxia. Hypoxia often leads to tachycardia (increased heart rate) as the body tries to compensate for low oxygen levels.
Hypotension - While severe hypoxia can eventually lead to changes in blood pressure, hypotension (low blood pressure) is not a primary sign of hypoxia. Typically, hypoxia might cause hypertension or have no immediate impact on blood pressure.
Nausea and Vomiting - While nausea and vomiting can be related to various conditions, they are not specific signs of hypoxia. These symptoms might occur due to other issues or as a secondary effect in some cases, but they are not primary indicators of hypoxia.

A. The nurse applies sterile gloves and touches a sterile object in the sterile field. B. The nurse disposes of an opened container of sterile saline after 24 hours. C. The nurse turns and their back is facing the sterile field. D. The nurse keeps hands above waist level while donning sterile gloves.

Correct Answer is C

Explanation

Correct answer: C

C. The nurse turns and their back is facing the sterile field.Turning one’s back to the sterile field is a breach of sterile technique because it increases the risk of contamination. The sterile field must always be in the nurse’s line of sight to ensure it remains uncontaminated.

Incorrect Options:

A. The nurse applies sterile gloves and touches a sterile object in the sterile field.This is correct practice. Sterile gloves are used to handle sterile objects within the sterile field to maintain sterility.

B. The nurse disposes of an opened container of sterile saline after 24 hours.This is correct practice. Sterile saline should be discarded after 24 hours to prevent contamination.

D. The nurse keeps hands above waist level while donning sterile gloves.This is correct practice. Keeping hands above waist level helps maintain sterility by preventing contact with non-sterile surfaces.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a patient and notes that the patient is experiencing hypoxia. Which of the following patient signs would indicate that the patient has hypoxia? Select all that apply.

Correct Answer is ["A","B","C","D","E"]

Explanation

A new perioperative nurse is being educated regarding surgical asepsis. What observations by the preceptor would indicate that there is a need for further education and reinforcement of the principles of asepsis?

Correct Answer is C

Explanation

A dietitian is providing an in-service for the nurses on a medical-surgical unit. During the in-service, the dietitian informs the group that there are six classes of nutrients, and three supply the body with energy. Which of the following are the three energy supplying nutrients?

An obese client is visiting a medical clinic seeking advice on ways to eat healthy and lose weight. The nurse should recommend which of the following to be included in the client's diet?

Which statement by a nurse would be the most therapeutic response to a patient who cannot decide if they want to receive recommended chemotherapy treatment?

A nurse is teaching a preoperative patient how to use an incentive spirometer. Which instruction should be included in the education to the patient?

A nurse asks a client the current level of pain using a scale of 0 to 10 after administering pain medications 30 minutes ago. Which of the following steps of the nursing process is the nurse performing?

A nurse is caring for a client who is being treated for bladder infection. The client reports to the nurse that he has been having painful burning with urination. How should the nurse document the client's condition?

A patient has an order for Normal Saline 1000 mL to infuse over 3 hours. The medication will be infused with an IV pump. How many mL/h should the IV pump be programmed for?

A new nurse understands that documentation guidelines are important to ensure accuracy. The nurse would perform which of the following documentation guidelines? Select all that apply.