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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Soft-serve ice cream contains dairy and sugar, which can worsen nausea for chemotherapy patients. Its high fat content may also contribute to gastrointestinal discomfort, making it an unsuitable food choice for managing nausea.
Choice B rationale
Hot tea, especially caffeinated varieties, may irritate the gastrointestinal lining and exacerbate nausea. While herbal teas could be soothing, this option does not explicitly align with the dietary recommendations for nausea management.
Choice C rationale
String cheese offers a protein-rich, low-fat option that is easy on the stomach and unlikely to exacerbate nausea. It aligns with dietary recommendations for managing chemotherapy-induced symptoms due to its mild taste and nutritional benefits.
Choice D rationale
Raisin toast contains fiber, which can be challenging to digest during nausea episodes, potentially worsening symptoms. Its texture and sweetness may also increase the risk of gastrointestinal upset, making it less suitable than other options. .
Correct Answer is B
Explanation
Choice A rationale
Applying wrist restraints immediately is an invasive intervention that may escalate the client’s agitation and anger. Restraints are used when absolutely necessary to prevent harm, and only after other de-escalation techniques have failed. Their use may breach the least restrictive intervention principle, which prioritizes non-invasive measures first.
Choice B rationale
Engaging the client in a repetitive activity acts as a distraction and can reduce agitation by refocusing their attention. This technique aligns with dementia care principles, emphasizing non-pharmacological interventions to manage behavioral disturbances. By promoting sensory engagement, it can help mitigate aggression effectively and respectfully.
Choice C rationale
Placing the client in a seclusion room can escalate feelings of confusion, isolation, and fear, worsening agitation. Seclusion should only be a last resort for safety reasons and not a first-line intervention in dementia care. It is contraindicated unless immediate harm is likely.
Choice D rationale
Administering haloperidol without first attempting non-pharmacological interventions disregards the principle of using medications judiciously. While haloperidol may calm agitation, side effects such as sedation or movement disorders make it inappropriate as a first-line option. This choice should follow other measures.
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