A nurse responds to the room of a client who is recovering from a cardiac arrest where CPR was performed. The client's child is distraught and tells the nurse that their parent has a do-not-resuscitate (DNR) prescription in their medical record. Which of the following actions should the nurse take first?

Report the occurrence to the nursing supervisor,

Complete an incident report stating the facts of the situation.

Verify the DNR prescription is current in the medical record.

Request a meeting with the ethics committee.

Answer and Explanation

The Correct Answer is C

A. Report the occurrence to the nursing supervisor:

While reporting the occurrence is important, verifying the DNR status takes precedence. The nurse needs to gather information and confirm whether the patient has a current DNR order before escalating the issue to a higher authority.

B. Complete an incident report stating the facts of the situation:

Completing an incident report is a part of the process, but it should not be the first action. The immediate concern is to determine if the patient has a valid DNR order. An incident report can be completed later to document the situation and any actions taken.

C. Verify the DNR prescription is current in the medical record.

Verifying the DNR (do-not-resuscitate) prescription is the first and most immediate action the nurse should take. It is crucial to confirm the current status of the DNR order to ensure that the healthcare team is following the patient's wishes. If the DNR is indeed valid and up-to-date, it means the resuscitation efforts, including CPR, were contrary to the patient's expressed wishes.

D. Request a meeting with the ethics committee:

Contacting the ethics committee may be necessary depending on the circumstances, but it is not the first step. Verifying the DNR status is an immediate action that can guide subsequent decisions. If there are ethical concerns or conflicts, involving the ethics committee can be considered after confirming the facts surrounding the DNR order.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

A. Initiate a 24-hr urine collection for a client who has end-stage kidney disease:

While a 24-hour urine collection is important for assessing kidney function, it is not an urgent task and can be scheduled at a later time without compromising the client's immediate well-being.

B. Change the dressing for a client who has a decubitus ulcer:

Changing the dressing for a decubitus ulcer is important for wound care, but it is not as urgent as addressing respiratory distress in a client with COPD.

C. Administer an antibiotic for a client who has methicillin-resistant Staphylococcus aureus:

Administering an antibiotic for a client with a methicillin-resistant Staphylococcus aureus (MRSA) infection is important, but it is not as immediately critical as ensuring adequate oxygenation in a client with COPD. Respiratory issues take precedence in the hierarchy of priorities.

D. Initiate oxygen therapy via nasal cannula for a client who has COPD.

The priority should be given to tasks that address immediate threats to the client's well-being or safety. In this scenario, initiating oxygen therapy for a client with COPD is a priority because it addresses respiratory distress and hypoxia, which are critical concerns in individuals with COPD. Respiratory interventions take precedence to ensure adequate oxygenation.

A. A client who has ascites and had a paracentesis 4 hr ago B. A client who is 6 hr postoperative following a hip arthroplasty C. A client who has a blood glucose level of 380 mg/dL and is receiving insulin via IV infusion D. A client who has pneumonia and is receiving 100% oxygen via a nonrebreather mask

Correct Answer is A

Explanation

This client has undergone a paracentesis for ascites, and since it was done 4 hours ago, they are likely stable and can be considered for discharge.

The client who is 6 hours postoperative following a hip arthroplasty may still require close monitoring and postoperative care. Discharging a postoperative client too early could lead to complications.

The client with a blood glucose level of 380 mg/dL receiving insulin via IV infusion requires ongoing monitoring and management of their diabetes. Discharging this client during an external disaster may not be appropriate due to the need for continued medical intervention.

The client with pneumonia receiving 100% oxygen via a nonrebreather mask likely requires continued medical attention and monitoring. Discharging a client with pneumonia who requires high-flow oxygen can pose risks to their respiratory status.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is prioritizing care for four clients. Which of the following tasks should the nurse perform first?

Correct Answer is D

Explanation

A nurse is selecting clients for discharge due to a local external disaster. Which of the following clients should the nurse recommend for discharge?

Correct Answer is A

Explanation

A nurse at a long-term care facility is assisting with teaching staff about infection control practices. Which of the following examples should the nurse include as an infection control hazard?

A nurse is asked by the unit manager to provide input for the performance appraisal of an assistive personnel (AP). Which of the following actions should the nurse take?

A nurse is reviewing the prescriptions for a client who is postoperative following a total hip arthroplasty. Which of the following prescriptions should the nurse clarify with the provider?

A nurse is planning care for four clients. Which of the following tasks are within the nurse's scope of practice?

A nurse is preparing to administer lactated Ringer's 250 mL IV to infuse over 30 min. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is preparing to administer calcitonin 8 units/kg IM to a client who weighs 165 lb. Available is 200 units/mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is caring for a client who has difficulty with fine motor skills due to rheumatoid arthritis. Which of the following referrals should the nurse recommend?