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 C

Explanation

C. A tort is a wrongful act or an infringement of a right that leads to civil legal liability. Restraint use should be based on a healthcare provider's order and should follow institutional policies and procedures. Administering restraints without proper authorization can result in legal liability, as it may constitute false imprisonment or battery.
A. In an emergency situation where a client is agitated and poses a risk to themselves or others, it may be necessary to enlist security personnel to help ensure the safety of everyone involved.
B. Administering medication behind a closed curtain is a common practice to provide privacy and confidentiality to the client.
D. Intentionally misleading a client about the nature of the medication being administered constitutes a form of deceit or fraud. However, this is not considered a tort.

A. Request removal initiated by the Health Information Manager. B. Create an electronic correction after 1400 notes are officially unlocked. C. Make an electronic addendum following the 1400 documentation. D. Enter the occurrence after the 1400 notes and identify as "late entry".

Correct Answer is D

Explanation

D. "Late entry" documentation is a common practice used to indicate that the entry was made after the designated time period. This allows for accurate recording of events while maintaining the integrity of the medical record. By entering the occurrence after the 1400 notes and clearly identifying it as a late entry, the nurse ensures that the information is documented appropriately and is easily identifiable as having been entered after the intended time.
A. This might be appropriate if the previously entered information was incorrect or inaccurate, and it needs to be completely removed from the record. However, it might not be necessary if the information is simply incomplete or if adding an addendum is sufficient.
B. Corrections are typically used to fix errors or inaccuracies in documentation, rather than adding new information that was missed. Adding a correction may not be the best approach for documenting a missed occurrence from a previous time, as it may not provide proper context or clarity.
C. An addendum is typically added to a patient's medical record to provide supplementary information or clarification regarding a specific aspect of the patient's care or condition.

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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 preparing to give an emergency sedative injection to an agitated client. Which action by the nurse comprises a tort?

Correct Answer is C

Explanation

After completing daily charting at 1400, the nurse realizes that a 0900 occurrence was not entered. Which is the best way for the nurse to enter computer documentation of the 0900 occurrence?

Correct Answer is D

Explanation

Patient Data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

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The nurse is demonstrating three-point gait crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior indicates that the client understands proper crutch walking?

A nurse administers an opioid analgesic to a postoperative client who also has severe obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client alone?

A client with a family history of cardiac disease is seeking information to control risk factors. Which lifestyle modification is most important for the nurse to encourage?

The nurse is interviewing a client with lower abdominal pain and dysuria, and needs to question the client about sexual activity. Which approach is best for the nurse to use?

Patient Data Exhibits Review H and P, nurse's notes, flow sheet, laboratory values, orders, and imaging studies. What times should the nurse measure vital signs? Select all that apply.