A nurse is caring for a client who has an end-stage lung disease. The client requests not to be resuscitated if their condition worsens. Which of the following actions should the nurse take?
Explain to the client what it means to change their code status.
Place a sign with “Do Not Resuscitate” outside the client’s room.
Obtain consent from the family to change the plan of care.
Document the client’s request in the medical record.
Correct Answer : A,D
Choice A reason: Explaining the implications of a Do Not Resuscitate (DNR) status ensures the client understands that no CPR or intubation will occur if their condition deteriorates. This supports informed consent and autonomy, clarifying the scope of DNR to prevent misunderstandings. It respects the client’s decision-making capacity, ensuring their wishes align with end-of-life care preferences.
Choice B reason: Placing a “Do Not Resuscitate” sign outside the room breaches confidentiality under HIPAA, risking unauthorized disclosure of sensitive information. DNR status is communicated via medical records or wristbands. This action is inappropriate, as it does not contribute to implementing the client’s wishes and violates privacy standards, making it an incorrect response.
Choice C reason: Obtaining family consent is unnecessary for a competent client’s DNR request, as autonomy rests with the client. If decisionally capable, their wishes override family input. The nurse’s role is to support the client’s decision, not seek family approval, unless the client is incapacitated, which is not indicated, making this action inappropriate.
Choice D reason: Documenting the DNR request in the medical record ensures the care team follows the client’s wishes, preventing unwanted interventions. Accurate documentation communicates code status, supports legal and ethical standards, and ensures continuity of care. This is critical for aligning treatment with the client’s end-of-life preferences, making it a necessary action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Avoiding physical exercise is not recommended for multiple sclerosis, as moderate activity like walking or stretching improves muscle strength, balance, and fatigue management. Complete avoidance leads to deconditioning, worsening mobility and fatigue, which are common in MS, making this instruction counterproductive to symptom management.
Choice B reason: Taking hot baths is not advised for multiple sclerosis, as heat can exacerbate symptoms like fatigue and muscle weakness due to temperature sensitivity (Uhthoff’s phenomenon). Cool or lukewarm baths are safer, supporting symptom control, making this instruction harmful and inappropriate for MS management.
Choice C reason: Performing daily stretching exercises improves flexibility, reduces spasticity, and enhances mobility in multiple sclerosis. Stretching strengthens muscles and prevents contractures, supporting functional independence. This aligns with evidence-based MS management to mitigate symptoms and improve quality of life, making it the correct instruction.
Choice D reason: Limiting fluid intake to reduce bladder irritation is inappropriate, as adequate hydration (2-3 L/day) prevents urinary tract infections, common in MS due to bladder dysfunction. Fluid restriction can worsen symptoms and dehydration, making this instruction incorrect for managing MS-related bladder issues effectively.
Correct Answer is A
Explanation
Choice A reason: Discussing the prescription with the provider is critical, as amoxicillin, a penicillin derivative, is contraindicated in clients with penicillin allergies due to risk of anaphylaxis. This ensures patient safety by verifying or correcting the order, aligning with nursing advocacy and safety protocols, making it correct.
Choice B reason: Administering amoxicillin to a client with a penicillin allergy risks severe allergic reactions, including anaphylaxis, violating patient safety principles. Nurses must verify contraindicated orders before administration, making this action dangerous and incorrect in this scenario.
Choice C reason: Placing an incident report is premature, as no error has occurred yet. The nurse’s role is to prevent harm by addressing the contraindicated prescription proactively. This action does not resolve the issue and is inappropriate as the first step, making it incorrect.
Choice D reason: Calling the pharmacist for clarification is less direct than discussing with the provider, who issued the order. While pharmacists can provide guidance, the provider must confirm or change the prescription to ensure safety, making this action secondary and less effective.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.