An older adult client with heart failure has a signed do not resuscitate (DNR) form to put in the medical record. The unlicensed assistive personnel (UAP) reports that the client is not breathing, and the nurse confirms the UAP's findings. Which action should the nurse take next?

Begin cardiopulmonary resuscitation (CPR) and call a code.

Ask the UAP to complete postmortem care.

Notify the family of the client's death.

Report client's status to the healthcare provider.

Answer and Explanation

The Correct Answer is D

D. The healthcare provider is mandated to perform a examination of the client and confirm death before any announcements to the family.
A. The DNR order indicates that the client has chosen not to receive CPR, so beginning resuscitation would go against their wishes.
B. Postmortem care is typically performed after the healthcare provider has pronounced the death
C. notifying the family is usually done after the healthcare provider has been informed and death has been confirmed.

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Correct Answer is A

Explanation

A. A well-approximated incision site refers to the edges of the surgical incision being closely aligned and in good alignment with minimal separation.
This finding is indicative of proper wound closure and initial stages of healing. It suggests that the wound edges are healing together, which is essential for preventing complications such as infection and promoting optimal wound healing.
B. Beefy red granulation tissue is a sign of the proliferative phase of wound healing. It appears as healthy, pinkish-red tissue that fills in the wound bed.
Granulation tissue consists of new blood vessels, fibroblasts, and connective tissue, and it serves to support wound healing by providing a scaffolding for tissue repair and promoting angiogenesis (formation of new blood vessels).
While the presence of granulation tissue is a positive sign indicating that the wound is progressing through the healing process, it typically occurs later in the healing timeline, beyond the initial one- week post-surgery period.
C. Eschar and slough are non-viable tissue components that can be present in a wound. Eschar is typically dry, black, or brown necrotic tissue, while slough is moist, yellow, or white necrotic tissue.
The presence of eschar and slough in a wound indicates that there is still non-viable tissue present that needs to be removed to facilitate healing.
D. Erythema (redness) and serosanguineous exudate (clear to blood-tinged fluid) are common findings in the early inflammatory phase of wound healing.
While some degree of erythema and serosanguineous exudate may be expected in the immediate postoperative period, especially within the first few days, persistent or increasing erythema and exudate beyond one week post-surgery may indicate inflammation or infection.

A. Encourage increased fluid intake and measure urinary output every 8 hours. B. Implement a 24-hour schedule of routine administration of prescribed analgesic. C. Determine client's subjective measure of pain using a numerical pain scale. D. Provide comfort measures such as topical warm application and tactile massage. E. Assist the client to ambulate as much as possible during waking hours.

Correct Answer is ["B","C","D"]

Explanation

B. Implementing a 24-hour schedule of routine analgesic administration ensures consistent pain control and helps prevent breakthrough pain.
C. Determining the client's subjective measure of pain using a numerical pain scale allows the nurse to assess the severity of the pain and monitor changes over time, which is essential for effective pain management.
D. Providing comfort measures such as topical warm application and tactile massage can help alleviate pain and provide relief to the client. These measures are non-pharmacological interventions that can complement analgesic therapy and improve the client's comfort level.
A. Encouraging increased fluid intake can help prevent dehydration and promote overall well-being, but it may not directly address chronic pain management. However, monitoring urinary output is important for assessing hydration status and renal function.
E. Encouraging mobility and physical activity is important for maintaining overall function and preventing complications associated with immobility. However, it may not directly address chronic pain management.

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An older adult client with heart failure has a signed do not resuscitate (DNR) form to put in the medical record. The unlicensed assistive personnel (UAP) reports that the client is not breathing, and the nurse confirms the UAP's findings. Which action should the nurse take next?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client one-week postsurgery. Which finding should the nurse expect to see if the surgical incision is healing properly?

Correct Answer is A

Explanation

The nurse is reviewing the admission assessment of a client with chronic pain. What intervention(s) should the nurse include in the client's plan of care? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

The nurse is using guided imagery with a client who is experiencing chronic pain. The nurse should direct the client's attention on which focus?

A client receives a prescription for dextromethorphan 30 mg every 6 to 8 hours PO as needed for cough. The bottle is labeled "Dextromethorphan for Oral Suspension, USP 30 mg per 15 mL." How many tablespoons should the nurse instruct the client to take with each dose? (Enter numerical value only.)

A hospitalized client who has an advance directive and healthcare power of attorney is receiving enteral nutrition through a nasogastric (NG) tube. The client vomits and appears to be choking. Which action should the nurse take?

The nurse is obtaining a systolic blood pressure by palpation. While inflating the cuff, the radial pulse is no longer palpable at 90 mm Hg. Which action should the nurse take?

The nurse plans to use the Situation, Background, Assessment, and Recommendation (SBAR) format of communication during which interaction?

The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?

A client who is paraplegic is admitted with a foul-smelling drainage from a sacral ulcer. The client is suspected to have a methicillin resistant Staphylococcus aureus (MRSA) infection. Which nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

When assuming care of a client at 1900, the nurse learns in report that a client with a urinary tract infection had an indwelling urinary catheter removed during the previous shift. Which information is most important for the nurse to obtain?