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.

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Correct Answer is ["C","E"]

Explanation

The nursing actions that best represent the step of performing interventions in the nursing process are:

C. The nurse ambulates a post-operative patient in the hall during their shift.

E. The nurse turns a patient every 2 hours to prevent pressure injuries.

Explanation: In the step of performing interventions, the nurse takes action to implement the nursing care plan and achieve the identified goals. The interventions should be specific, measurable, and realistic to address the patient's needs. Ambulating a post-operative patient in the hall during their shift and turning a patient every 2 hours to prevent pressure injuries are both specific interventions that address patient needs and promote positive health outcomes. Removing bandages from a burn victim's arm and performing sterile dressing change once a shift is more related to the step of assessment or implementation, while identifying a patient's priority health problem or assessing a patient's nutritional status are more related to the step of analysis and diagnosis in the nursing process.

A. Apply restraints to the hands or wrists to keep the patient in bed. B. Place a belt restraint on the client when they are sitting in a chair. C. Keep the bed in lowest position with all four side rails up. D. Educate the patient on using the call light and make sure the call light is within reach.

Correct Answer is D

Explanation

A. Apply restraints to the hands or wrists to keep the patient in bed:Restraints should only be used when absolutely necessary and as a last resort, and the client in this scenario is oriented and can follow instructions. Restraints can also increase the risk of injury, agitation, and further falls.

B. Place a belt restraint on the client when they are sitting in a chair:Belt restraints restrict movement and should only be used when other measures are insufficient to protect the client. Since the client is oriented and can follow directions, this intervention is not warranted and could cause harm.

C. Keep the bed in the lowest position with all four side rails up:
Incorrect. Raising all four side rails is considered a form of restraint and can increase the risk of injury. Clients may attempt to climb over the side rails, leading to falls. Keeping the bed in a low position is appropriate, but using all four side rails is not.

D. Educate the patient on using the call light and make sure the call light is within reach.This is the most appropriate action as the client is oriented and can follow directions. Educating the patient on how to use the call light and ensuring it is easily accessible encourages them to ask for assistance when needed, reducing the risk of falls.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is taking action and performing interventions in the nursing process to provide care for patients in a busy hospital setting. Which nursing actions best represent this step in the nursing process? Select all that apply.

Correct Answer is ["C","E"]

Explanation

A nurse is caring for a client who has a history of falling at their assisted living facility. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall?

Correct Answer is D

Explanation

The nurse is planning to care for a client with an indwelling catheter. Which of the following measures should the nurse implement when performing hygiene care in regards to the indwelling catheter?

A nurse is using the SOAP documentation format to chart on their patient in a systematic and organized way. When using SOAP, what sections would be present in the charting? Select all that apply.

The physician orders penicillin G 1,000,000 units IM. The label on the vial of powdered penicillin G reads to reconstitute with 1.6 mL of sterile water to achieve a concentration of 5,000,000 units/mL. How many mL will the nurse give to the client for the ordered dose?

A nurse can most accurately assess a client's apical heart rate by which of the following methods?

The nurse has assessed the client, analyzed the data, and identified constipation as a patient health problem. Which assessment cues would support constipation? Select all that apply.

A new patient is admitted to a medical unit with Clostridium difficile (C-diff). Which type of precautions or isolation should the nurse apply for this patient?

A nurse caring for a post-operative client observes the drainage in the client's closed wound drainage system. The drainage is dark red in color. The nurse documents the drainage as which of the following?