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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Free Nursing Study Resources

Correct Answer is ["725"]

Explanation

Intake = IV fluid + antibiotic

From 0700-0900 (2 hours), the patient received 100 mL/hr of IV fluid: 100 mL/hr x 2 hours = 200 mL

From 1000-1030 (0.5 hours), the patient received Kefzol 1 g in 25 mL of D5W over 30 minutes:

25 mL

From 1030-1530 (5 hours), the patient received 100 mL/hr of IV fluid: 100 mL/hr x 5 hours = 500 mL

Total intake from 0700-1530 = 200 mL + 25 mL + 500 mL = 725 mL. Therefore, the patient's intake from 0700 to 1530 was 725 mL.

A. The client's sense of loss can be lessened through retaining dignity and control of certain areas of their life such as ADLs. B. Allowing the client to function independently will strengthen their muscles and promote healing from the illness. C. The client's decision in regards to their care should not influence their family's decision to assist with ADLs. D. The ADLs can only be performed by a member of the healthcare team.

Correct Answer is A

Explanation

The correct answer is choice A. The rationale for self-care that the nurse should communicate to the client's family is that the client's sense of loss can be lessened through retaining dignity and control of certain areas of their life such as ADLs. Allowing the client to perform self-care activities independently, to the extent possible, promotes the client's autonomy and helps to preserve their selfesteem and sense of control over their life. As the client nears the end of life, it is important to respect their wishes and promote their comfort and well-being in every way possible.

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["725"]

Explanation

A nurse is caring for an alert and oriented client who has terminal lung cancer. The nurse observes the client's family assisting with all ADLs. Which of the following rationales for self-care should the nurse communicate to the family on behalf of the client?

Correct Answer is A

Explanation

Kübler-Ross defines five stages of psychosocial responses to dying and death. Which of the following statements is characteristic of the denial stage?

The nurse is teaching a post-operative client about the purpose of their surgical drain. The nurse should include in this teaching which of the following statements regarding the purpose of the Jackson-Pratt (JP) drain?

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.

A nurse is providing education to a client diagnosed with insomnia. What sleeppromoting techniques would the nurse suggest to help the client's condition? Select all that apply.

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 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?