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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Before administering a cleansing enema, the client is typically instructed to assume a left-side lying position with the right knee bent. This position helps to facilitate the flow of the enema solution into the colon and allows for better retention of the solution. It also helps to prevent leakage and discomfort during the procedure.

A. Drinking water before administering an enema can help hydrate the client and promote normal bowel function. However, it is not typically a specific instruction related to the administration of the enema itself. Hydration is generally beneficial for bowel health but is not directly related to the enema procedure.
B. After administering the enema solution, the client should be instructed to hold the solution in the bowel for a sufficient amount of time to allow it to soften and loosen stool. The exact duration can vary based on the type and purpose of the enema, but typically, the client is encouraged to retain the solution for a specified period (as instructed by the healthcare provider) before evacuating.
C. This instruction is unrelated to the administration of a cleansing enema. Breathing techniques may be taught for relaxation or to manage discomfort during procedures, but they do not specifically apply to the process of administering an enema.
Correct Answer is C
Explanation
C. A comprehensive approach ensures that all aspects of patient care, safety, and organizational processes are thoroughly reviewed and addressed according to TJC standards. This includes comprehensive assessments of patient needs, care plans, and quality improvement initiatives.
A. This term typically refers to the process of capturing images or videos at intervals over time. In the context of healthcare and TJC requirements, "time-lapsed" is not a standard term used by TJC.
B An emergency situation refers to a sudden and often critical medical situation requiring immediate attention and intervention. While TJC does have standards related to emergency preparedness and response in healthcare facilities, "emergency" is not specifically a type of TJC requirement in the context provided.
D. A focused approach refers to concentrating on specific areas or issues within healthcare organizations to address particular concerns or improvements. However, this is not specific about TJC.
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