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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. The nurse should maintain HIPAA compliance by not sharing any patient information with a non-designated person, even if they identify as a family friend. The nurse should inform the visitor that they cannot share any patient information and suggest that they talk to the patient's family directly if they wish to offer assistance. It is important to protect patient privacy and confidentiality and to only share information with authorized individuals who have a legitimate need to know.
Correct Answer is A
Explanation
A pureed diet is a type of texture-modified diet where food is blended to a smooth consistency to make it easier to swallow. Nectar-thick liquids are liquids that have a slightly thicker consistency than water, which makes them easier for the client to swallow without choking or aspirating.
Options B, C, and D are not appropriate for a client with dysphagia on a pureed diet with nectar-thick liquids. Corn on the cob is a hard, crunchy food that is difficult to puree, while a hamburger and a salad are both difficult to make into a smooth consistency. These foods could pose a choking or aspiration risk for the client.
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