An older adult woman with end stage heart disease is alert and oriented and states that she does not want any heroic measures taken in the event she stops breathing. The client's children tell the nurse that they accept their mother's wishes and do not want to watch her suffer. Which action should the nurse take first?

Consult the palliative care team.

Obtain a do not resuscitate prescription.

Define the term heroic measures.

Coordinate a family conference.

Answer and Explanation

The Correct Answer is B

Choice A reason: Consulting the palliative care team is an important action for the nurse to take, but not the first one. The palliative care team can provide holistic and compassionate care to the client and the family and help them cope with the end-of-life issues. However, the nurse should first obtain a do not resuscitate prescription from the healthcare provider to ensure that the client's wishes are respected and followed.

Choice B reason: Obtaining a do not resuscitate prescription is the first action for the nurse to take. The do not resuscitate prescription is a legal document that states that the client does not want any cardiopulmonary resuscitation or other life-sustaining interventions in the event of cardiac or respiratory arrest. The nurse should obtain the prescription from the healthcare provider and document it in the client's chart. The nurse should also inform the staff and the family about the prescription and its implications.

Choice C reason: Defining the term heroic measures is not the first action for the nurse to take. The term heroic measures is vague and subjective and may mean different things to different people. The nurse should clarify with the client and the family what they consider as heroic measures and what they want to avoid or accept. However, the nurse should first obtain a do not resuscitate prescription to ensure that the client's wishes are legally binding and clear.

Choice D reason: Coordinating a family conference is not the first action for the nurse to take. The family conference is a meeting where the client, the family, the healthcare provider, and the nurse can discuss the goals and plans of care and address any concerns or questions. The family conference can facilitate communication and decision-making and promote mutual understanding and support. However, the nurse should first obtain a do not resuscitate prescription to ensure that the client's wishes are honored and communicated.

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Correct Answer is C

Explanation

Choice A reason: A child who has had a cold for two days and now is coughing up green sputum is not the most urgent client to assess. The child may have a bacterial infection that requires antibiotics, but the condition is not life-threatening or unstable. The child can be classified as urgent and seen within one hour.

Choice B reason: A male adolescent who has been vomiting for the past 12 hours and describes himself as very weak is not the most urgent client to assess. The adolescent may have dehydration, electrolyte imbalance, or gastroenteritis that requires fluid replacement and antiemetics, but the condition is not life-threatening or unstable. The adolescent can be classified as urgent and seen within one hour.

Choice C reason: A female client with severe right lower abdominal pain who is febrile and vomiting is the most urgent client to assess. The client may have appendicitis, ovarian torsion, ectopic pregnancy, or another serious condition that requires immediate diagnosis and treatment. The client is at risk of perforation, infection, shock, or hemorrhage and needs to be seen as soon as possible. The client can be classified as emergent and seen within 15 minutes.

Choice D reason: An elderly client with peripheral vascular disease who is complaining of severe leg pain when ambulating is not the most urgent client to assess. The client may have intermittent claudication, ischemia, or ulceration that requires analgesics, antiplatelets, or vascular surgery, but the condition is not life-threatening or unstable. The client can be classified as semi-urgent and seen within two hours.

A. Assign the UAP to provide care for another client and assume full care of the client. B. Remind the UAP to apply a fitted respirator mask before entering the client's room. C. Review the need for the UAP to wear a face mask while in close contact with the client. D. Instruct the UAP to notify the nurse of any changes in the client's respiratory status.

Correct Answer is C

Explanation

Choice A reason: Assigning the UAP to provide care for another client and assuming full care of the client is not the best action for the nurse to take. This may disrupt the continuity of care and the rapport between the UAP and the client. It may also be unnecessary and inefficient for the nurse to take over the care of the client.

Choice B reason: Reminding the UAP to apply a fitted respirator mask before entering the client's room is not the best action for the nurse to take. This may be incorrect and inappropriate for the prevention of pertussis transmission. A fitted respirator mask is used for airborne precautions, while pertussis is spread by droplet contact.

Choice C reason: Reviewing the need for the UAP to wear a face mask while in close contact with the client is the best action for the nurse to take. This can educate the UAP about the proper infection control measures for pertussis, which include droplet precautions. A face mask can prevent the UAP from inhaling or spreading the droplets that contain the bacteria.

Choice D reason: Instructing the UAP to notify the nurse of any changes in the client's respiratory status is not the best action for the nurse to take. This may be irrelevant and redundant for the situation. The UAP should already know to report any changes in the client's condition to the nurse, regardless of the diagnosis or the intervention.

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Naxlex Comprehensive Predictor Exams

When triaging emergency room clients, which client should the nurse assess first?

Correct Answer is C

Explanation

A child is admitted to the pediatric unit after being diagnosed with pertussis. The nurse observes an unlicensed assistive personnel (UAP) donning a pair of gloves before entering the room to give the child a popsicle. Which action should the nurse take?

Correct Answer is C

Explanation

A group of nurse managers is asked to engage in a needs assessment for a piece of equipment that will be expensed to the organization's budget. Which question is most important to consider when analyzing the cost-benefit for this piece of equipment?

Several family members are visiting a client who had a myocardial infarction 4 days ago. The unlicensed assistive personnel (UAP) informs the nurse that one of the visitors is lying on the client's bed. Which action should the nurse implement?

A client with life-threatening injuries from a gunshot wound to the abdomen is mechanically ventilated and sedated. The client has a large family present who are asking multiple and repetitive questions. Which intervention should the nurse implement first?

An unlicensed assistive personnel (UAP) who is working on a skilled nursing unit is diagnosed with hepatitis A (HVA). Two weeks later, a nurse complains of headache, nausea, anorexia, arthralgia, and low-grade fever. Which action should the nurse-manager take next?

Which staff assignment, made by the primary nurse, requires the most immediate follow-up action by the charge nurse on a medical unit?

The nurse is assisting with a lumbar puncture on a client. During the procedure, a code is called for another client on the unit who is experiencing respiratory arrest. Which action should the nurse take?

The charge nurse needs to determine if an additional nurse should be called to help staff the unit for the next shift. Which information is most important for the charge nurse to consider when making this decision?