A nurse enters a client's room and finds the client pulseless. The family has requested a do-not-resuscitate (DNR) order from the provider, but he has not written the order yet. Which of the following actions should the nurse take?

Call the provider for a stat DNR order.

Call the emergency response team.

Seek immediate help from the risk manager.

Respect the family's wishes and do nothing.

Answer and Explanation

The Correct Answer is B

Rationale:

A. Call the provider for a stat DNR order is not appropriate as the client is already in a critical state requiring immediate action.

B. Call the emergency response team is necessary as the client is pulseless, and resuscitation should be initiated according to standard procedures until a DNR order is confirmed.

C. Seek immediate help from the risk manager is not appropriate at this moment; the immediate concern is the client's emergency situation.

D. Respect the family's wishes and do nothing is not appropriate as immediate life-saving measures should be taken until a formal DNR order is in place.

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"}}

Explanation

Client 3: Collect and label specimen.

Assistive personnel- Assistive personnel can handle the collection and labeling of specimens, which is a routine task that does not require advanced clinical judgment.

Client 1: Perform prescribed procedure.

Practical Nurse- Insertion of a nasogastric tube is a procedure that requires clinical skills and knowledge, making it appropriate for a licensed practical nurse (LPN) to perform.

Client 3: Administer prescribed medication.

Practical Nurse- Administering medication is within the scope of practice for a practical nurse, as they are trained to handle medications and monitor their effects.

Client 4: Perform prescribed testing.

Assistive personnel- Testing such as using a glucometer for blood glucose monitoring can be performed by assistive personnel under the supervision of a registered nurse or practical nurse.

Client 4: Provide prescribed wound care.

Practical Nurse- Wound care, especially for a non-healing wound and cellulitis, requires clinical assessment and skills that a practical nurse is trained to provide.

Client 2: Transport client for diagnostic testing.

Assistive personnel- Transporting clients to diagnostic testing is a task that can be safely performed by assistive personnel.

A. A client who has a small circular partial-thickness burn of the left calf B. A client who has a massive head injury and is experiencing seizures C. A client who has a splinted open fracture of left medial malleolus D. A client who has severe respiratory stridor and a deviated trachea

Correct Answer is D

Explanation

Rationale:

A. A client who has a small circular partial-thickness burn of the left calf requires care, but this is less urgent compared to severe airway or respiratory issues.

B. A client who has a massive head injury and is experiencing seizures is critical but still less urgent compared to immediate life-threatening airway issues.

C. A client who has a splinted open fracture of left medial malleolus requires care but is not as immediately life-threatening as respiratory issues.

D. A client who has severe respiratory stridor and a deviated trachea has a life-threatening airway obstruction that needs immediate intervention to ensure adequate breathing and oxygenation.

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A nurse enters a client's room and finds the client pulseless. The family has requested a do-not-resuscitate (DNR) order from the provider, but he has not written the order yet. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The charge nurse is planning to delegate client care tasks. Exhibits For each task identify the team member to which the nurse should delegate the task. Each task may be appropriate for more than 1 team member.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"}}

Explanation

A nurse is triaging clients following a mass casualty event. Which of the following clients should the nurse assess first?

Correct Answer is D

Explanation

A nurse is triaging clients in the emergency department. Which of the following clients should the nurse ask the provider to care for first?

A nurse is planning care for four clients and is assigning tasks to a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following should the nurse assign to the LPN?

A nurse manager is observing the care provided by a nurse who is in orientation to the unit. Which of the following actions by the nurse indicates the nurse manager should intervene?

A nurse is caring for four clients who are postoperative from surgery 24 hr ago. At 1200 the nurse assesses the clients. Which of the following clients is the nurse's priority?

A nurse tells another nurse that she thinks he did not provide adequate care for a client who underwent hip arthroplasty. Which of the following responses by the nurse demonstrates assertiveness?

A nurse is receiving change-of-shift report at the start of the shift. Which of the following statements by the nurse giving report indicates to the oncoming nurse that she should assume total care for the client, rather than assigning tasks to the assistive personnel (AP)?

A nurse is planning to assign care activities to the assistive personnel (AP) on her team. Which of the following activities can the nurse assign to the AP? (Select all that apply.)