A nurse is caring for a client who has gone into cardiac arrest.
The client's chart indicates refusal of life-sustaining measures in a living will signed 10 years ago, but a do-not-resuscitate (DNR) prescription has not been written by the provider.
Which of the following actions by the nurse is appropriate?

Consult with the client's family regarding resuscitation efforts.

Comply with the living will and let the client expire naturally.

Call a code because a DNR prescription has not been written.

Contact the provider for instructions regarding a DNR.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Consulting with the client’s family would delay critical actions in an emergency. Additionally, family members cannot override the legal documentation of the client's wishes, such as a living will. Ethical guidelines prioritize the client's autonomy, but without a written DNR, the nurse should prioritize immediate life-saving efforts.

Choice B rationale

A living will outlines patient preferences, but it is not legally enforceable without a corresponding provider’s order. Complying with it without a written DNR could violate legal and professional standards. The nurse must initiate life-saving actions unless explicitly instructed otherwise by the provider.

Choice C rationale

Without a written DNR, the nurse must take measures to preserve life as per standard resuscitation guidelines. Legal protection applies to actions taken during a cardiac arrest to avoid negligence. This ensures that the client receives immediate care until proper clarification is made.

Choice D rationale

Contacting the provider during a cardiac arrest introduces a delay, increasing the risk of irreversible damage or death. While it is essential to clarify orders, emergency protocol dictates acting promptly to save the client’s life in the absence of clear documentation.

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Correct Answer is D

Explanation

Choice A rationale

Delaying surgery in an emergency violates the standard of care. When life-saving intervention is necessary, implied consent applies to act in the client’s best interests. Delaying for parental consent increases the risk of harm or mortality.

Choice B rationale

A pediatrician cannot grant consent in place of the legal guardians. Implied consent applies specifically to urgent situations where the client cannot consent, and the delay to contact a surrogate is not feasible.

Choice C rationale

A relative other than a parent or legal guardian cannot provide consent unless legally appointed. Emergency situations follow implied consent protocols when legal surrogates are unavailable. Proceeding with life-saving care does not require seeking extended family approval.

Choice D rationale

Implied consent is a legal principle used in emergencies to authorize necessary treatment when a legal guardian or proxy cannot be reached. This ensures timely intervention to prevent harm, especially for minors unable to consent themselves.

A. A client who has heart failure and has gained 1 kg (2.2 lb) in the last 48 hr. B. A client who has dementia and is experiencing paranoia. C. A client who has a pressure ulcer on the left heel that has progressed from stage II to stage III. D. A client who has a UTI and reports itching after receiving a dose of cefaclor PO.

Correct Answer is D

Explanation

Choice A rationale

A weight gain of 1 kg (2.2 lb) in 48 hours can be an early indicator of fluid retention in clients with heart failure. However, this change is not immediately life-threatening and can be addressed by monitoring or adjusting medications, making it lower priority compared to acute allergic reactions.

Choice B rationale

Paranoia in dementia clients reflects cognitive decline or psychological distress, which requires management but does not pose an immediate threat to physical health. It is important but not the highest priority for immediate reporting.

Choice C rationale

Progression of a pressure ulcer to stage III indicates worsening tissue damage, requiring evaluation of wound care strategies. However, this concern does not constitute an urgent situation compared to an acute allergic reaction that can compromise airway and systemic stability.

Choice D rationale

Itching after receiving cefaclor PO is a possible sign of an allergic reaction. Allergic reactions can escalate to anaphylaxis, posing immediate life-threatening risks. Recognizing and reporting this symptom promptly is critical for client safety.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a 16-year-old client who was in a motor-vehicle crash and needs surgical intervention immediately.The staff cannot reach either of the client's parents.The nurse should identify that which of the following is true about obtaining consent?

Correct Answer is D

Explanation

A nurse in a long-term care facility is caring for a group of clients.The nurse should recognize that which of the following information is the highest priority to report to the nursing supervisor?

Correct Answer is D

Explanation

A nurse is assisting with the plan of care for a client.Which of the following activities should the nurse include in the implementation phase of the nursing process?

A nurse is caring for a client who reports his medication was not given during the night shift for the past 3 nights.The medication administration record indicates the medication was given.Which of the following actions by the nurse is appropriate?

A nurse at a rehabilitation facility is planning to attend an interprofessional team meeting to discuss a client who is recovering from abdominal surgery.Which of the following actions should the nurse take to prepare for the meeting?

A nurse is collecting data from a client who is 1 day postoperative following a total hip arthroplasty.Which of the following findings is the priority for the nurse to report to the provider?

A nurse is collecting data from an older adult client during a home visit.Which of the following findings should the nurse report?

A charge nurse is observing the actions of the facility staff on the unit.Which of the following actions should the charge nurse identify as a possible legal issue?

A nurse is preparing to perform a dressing change for a client who has a nondraining, stage II pressure ulcer that is infected with methicillin-resistant Staphylococcus aureus (MRS

A nurse in a long-term care facility is caring for a client who received a superficial burn from a heating pad that malfunctioned.After completing an incident report, which of the following actions should the nurse take?