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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Restraints should only be used as a last resort when all other options have been exhausted and there is an immediate risk to the safety of the client or others.
B. This option promotes safety by allowing for easier monitoring of the client while also preventing them from feeling completely confined. It can reduce anxiety and promote a sense of autonomy. It is a less restrictive approach than using restraints.
C.A back rub can be a soothing and calming intervention that may help the client relax and potentially improve sleep quality. However, while this is a good comfort measure, it does not directly address the immediate concern of wandering and confusion.
D. Administering sedatives should be approached cautiously, especially in older adults, due to the increased risk of adverse effects such as confusion, falls, and respiratory depression.
Correct Answer is B
Explanation
B. Neuropathy can lead to decreased sensation in the feet, making the client less aware of potential injuries or skin breakdown. As a result, there is an increased risk for impaired skin integrity, including the development of pressure ulcers, blisters, or wounds. Promoting foot care is essential to prevent complications such as foot ulcers or infections.
A. Neuropathy can compromise the body's ability to detect injuries or wounds in the feet, increasing the risk of infection if injuries go unnoticed or untreated. However, while infection is a concern, the primary issue with neuropathy-related foot care is the risk of impaired skin integrity.
C. While self-care deficits may be addressed as part of the client's overall care plan, it is not the priority at this time compared to preventing skin breakdown and potential complications.
D. While impaired mobility may contribute to increased pressure on the feet and potential skin breakdown, the priority is addressing the immediate risk of impaired skin integrity due to neuropathy- related sensory deficits.
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