The nurse is caring for a client diagnosed with cancer. The client has discussed having a DNR order written but is undecided. The nurse enters the client's room with their domestic partner sitting at the client's bedside. The nurse assesses that the client is not breathing spontaneously & unresponsive. What is the first appropriate action by the nurse?

Assist the significant other out of the room.

Activate the facility's response system for a code

Inform the physician that the client is apneic.

Ask the client's partner to make a DNR decision immediately.

Answer and Explanation

The Correct Answer is B

B. Activating a code blue or the facility's emergency response system will bring immediate assistance and resources to the client's bedside. This is crucial to initiate prompt resuscitative measures if indicated and to involve additional healthcare providers in the management of the emergency.

A. While it might be appropriate in some situations to provide privacy or support to the partner, in this urgent scenario where the client is unresponsive and not breathing, the priority should be immediate assessment and intervention for the client's condition.

C. While notifying the physician is important, especially to inform them of the client's condition and potentially discuss the DNR status, it is not the most immediate action in this urgent situation where the client is unresponsive and not breathing. Direct intervention and assessment are needed first.

D. Asking the partner to make a DNR decision immediately is not appropriate as the first action in this scenario. It is crucial to focus first on the client's immediate needs for assessment and potentially resuscitative measures if indicated. The discussion about the DNR order should occur in a timely manner but is secondary to addressing the client's current medical emergency.

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Free Nursing Study Resources

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

Explanation

C. Rapid heart rate (tachycardia) can be a sign of fluid overload, as the heart compensates for increased volume by beating faster to maintain cardiac output.

D. Shortness of breath (dyspnea) can indicate fluid overload, especially if it is new or worsening and associated with pulmonary congestion due to fluid accumulation.

E Elevated blood pressure can be a sign of fluid overload, as increased circulating volume can lead to hypertension.

A. This statement suggests a decrease in peripheral edema, which is a positive sign and does not typically indicate fluid overload. It may actually indicate improvement.

B. Dizziness can be a symptom of hypovolemia (low fluid volume) rather than fluid overload. It is not typically a specific sign of fluid overload.

A. Exhaustion B. Resistance C. Alarm D. Recovery

Correct Answer is C

Explanation

C. If the stressor persists for a prolonged period and the body is unable to adapt or cope effectively, it enters the exhaustion phase. During this phase, the body's resources become depleted. The client experiences decreased energy, reduced ability to cope with stress, and may develop stress-related illnesses or complications.

A. It is characterized by the body's immediate response to a stressor, where physiological changes occur such as increased heart rate, heightened senses, and activation of the fight-or-flight response.

B. After the initial alarm reaction, if the stressor persists, the body enters the resistance phase. In this phase, physiological changes stabilize as the body attempts to cope with the stressor.

D. This phase occurs if the stressor is removed or successfully managed, allowing the body to recover and return to a state of homeostasis. During recovery, the body repairs any damage caused by the stress response and replenishes its energy and resources.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client receiving 0.9% NSS infusing at 150 mL/hr. Which statement(s) made by the client should alert the nurse to suspect fluid overload? (SELECT ALL THAT APPLY)

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

Explanation

The nurse recognizes that the client's energy has been depleted despite attempts to intervene and the client dies. This is a description of which phase of the General Adaptation Syndrome?

Correct Answer is C

Explanation

A client is brought into the emergency department for an overdose of morphine. The client has a respiratory rate of 5 to 8 breaths per minute. Which of the following ABG results would the nurse expect to see?

It is important for the nurse to ensure that the client's post-operative Jackson-Pratt device is patent because its purpose is to:

Because of the skin changes in the older adult client, what interventions should the nurse ensure in their care? (SELECT ALL THAT APPLY)

The newly admitted client has contractures of both lower extremities. What nursing intervention should be included in this client's plan of care?

Which statement indicates that the nurse understands what the half-life of a drug means?

The nurse is assessing internal variables that influence a client's health care beliefs and practices. As part of this assessment, the nurse should consider the client's:

To increase both the respiratory and circulatory functions of a nonresponsive client, what is the most important intervention for the nurse to perform?