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 D

Explanation

Rationale:

A. The nurse coats the indwelling urinary catheter with lubricant is correct and necessary for the procedure to reduce discomfort and facilitate insertion.

B. The nurse applies the sterile drape prior to inserting the urinary catheter is a proper step to maintain a sterile field during the procedure.

C. The nurse provides perineal care prior to inserting the urinary catheter is appropriate as it ensures cleanliness before catheter insertion.

D. The nurse separates the client's labia with her dominant hand should not be done; the non-dominant hand should be used to hold the labia apart to maintain sterility.

A. A client who has COPD and the capillary refill time on both hands is 4 seconds B. A client who has late-stage cirrhosis and whose breath has a fruity odor C. A client who has a nasogastric tube for decompression and the gastric aspirate is green with a pH of 5.3 D. A client who had an indwelling urinary catheter removed 5 hr ago and has not voided

Correct Answer is D

Explanation

Rationale:

A. Capillary refill time of 4 seconds is concerning but less urgent compared to immediate post-catheter removal issues.

B. Fruity breath odor in late-stage cirrhosis could indicate a metabolic issue but is less immediate than issues related to urinary output.

C. Green gastric aspirate with a pH of 5.3 is within normal range for NG tube decompression.

D. A client who has not voided 5 hours after catheter removal is at risk for urinary retention or other complications and should be assessed immediately.

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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

A charge nurse is observing a nurse Insert an indwelling urinary catheter into a female client. For which of the following actions by the nurse should the charge nurse intervene?

Correct Answer is D

Explanation

A nurse is caring for four clients on a medical-surgical unit. Which of the following clients should the nurse assess first?

Correct Answer is D

Explanation

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