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.

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Correct Answer is C

Explanation

A. A staff member places a midstream urine sample in a specimen refrigerator after collecting it: This action is appropriate as long as the specimen is labeled correctly and stored at the correct temperature. Proper handling of specimens is essential for accurate testing and does not represent an infection control hazard.

B. A staff member wipes a countertop with chlorhexidine solution to clean the area following a blood spill: This action is appropriate for cleaning a contaminated surface. Chlorhexidine is an effective disinfectant for blood spills. Therefore, this action does not represent an infection control hazard.

C. A nurse uses alcohol-based antiseptic to clean his hands after talking with a client who has varicella zoster: While alcohol-based antiseptics are effective for most pathogens, varicella zosteris primarily spread through direct contact and airborne transmission. It is recommended to wash hands with soap and water after caring for a patient with varicella zoster, especially if hands are visibly soiled. This action may not adequately control the infection hazard.

D. A nurse pours sterile 0.9% sodium chloride irrigation solution on an open pressure wound prior to collecting a specimen for culture: This action is appropriate as long as sterile technique is maintained. Using sterile saline for irrigation is standard practice to minimize the risk of introducing pathogens before specimen collection. Therefore, this action does not represent an infection control hazard.

A. Hot tea B. Soft-serve ice cream C. Raisin toast D. String cheese

Correct Answer is C

Explanation

Hot tea:

Hot tea may not be well-tolerated by individuals experiencing chemotherapy-induced nausea, as hot or strong-smelling foods and beverages can be triggers. It is generally recommended to choose foods at room temperature.

Soft-serve ice cream:

Soft-serve ice cream may be too cold and could exacerbate nausea or discomfort. Cold foods might not be well-tolerated during or after chemotherapy.

Raisin toast:

This is the correct answer. Raisin toast is a good choice as it is a bland and easily digestible carbohydrate. It can be a suitable option for individuals experiencing nausea, providing some calories without strong odors or flavors.

String cheese:

While cheese can be a good source of protein, string cheese might not be the best choice if the individual is experiencing nausea, as the smell or taste of certain cheeses can be strong and trigger nausea.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

A nurse in a long-term care facility is reinforcing teaching with a newly licensed nurse about chemotherapy-induced nausea. Which of the following food selections indicates the newly licensed nurse understands the teaching?

Correct Answer is C

Explanation

A nurse is preparing to administer an intermittent enteral feeding through a small-bore NG tube. Which of the following actions should the nurse take before initiating the feeding?

A nurse is caring for an adult client who has a history of mental illness and is scheduled for a total hip arthroplasty. The nurse should Identify that which of the following people can provide informed consent for the procedure?

A charge nurse is reviewing ethical principles with a group of staff nurses. Which of the following statements by a staff nurse indicates an understanding of ethical principles?

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 assisting with the development of a nursing staff in-service about medication reconciliation. Which of the following instructions should the nurse recommend to include in the in-service?

A nurse is reviewing documentation on a group of clients as part of a quality improvement initiative. Which of the following actions should the nurse document as decreasing the risk for skin breakdown?

A nurse is documenting the care of a client in the computer when she is called to another client's room. Which of the following actions should the nurse take?

A home health nurse is caring for a group of older adult clients. The nurse should report which of the following clients to the case manager for findings consistent with elder abuse?