The nurse is caring for a client with a terminal illness who has become pulseless. The code status for the client is unknown to the nurse and a hospital emergency response is called. Which of the following actions should the nurse take?

Verify the client's code status.

Begin cardiopulmonary resuscitation.

Provide comfort measures until family arrives.

Initiate a slow code response.

Answer and Explanation

The Correct Answer is B

A. Verify the client's code status: Although verifying code status is important, it may delay necessary emergency interventions. In an urgent situation where the code status is unknown, immediate action is required.

B. Begin cardiopulmonary resuscitation (CPR). When a client is pulseless and the code status is unknown, the priority is to start CPR while emergency services are called. This ensures that the client receives potentially life-saving care promptly.

C. Provide comfort measures until family arrives. This is not appropriate if the client is pulseless and immediate resuscitation efforts are needed.

D. Initiate a slow code response. A slow code is not appropriate in an emergency situation where the patient requires immediate resuscitation.

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Correct Answer is A

Explanation

A. Obstructive sleep apnea: Obstructive sleep apnea is characterized by loud snoring, daytime drowsiness, and periods of waking up due to blocked airways. The client’s symptoms are consistent with this condition and warrant further assessment for it.

B. Circadian rhythm disorder: Circadian rhythm disorders involve disruptions in the sleep-wake cycle, but they are less likely to present with loud snoring and daytime drowsiness as primary symptoms.

C. Narcolepsy: Narcolepsy is characterized by excessive daytime sleepiness and sudden sleep attacks but does not typically include loud snoring or waking up from snoring.

D. Insomnia: Insomnia involves difficulty falling or staying asleep and would not typically cause daytime drowsiness from loud snoring or the described waking up issues.

A. Scrub the stem of the ampule with antimicrobial wipe. B. Break the stem of the ampule away from the body C. Attach a filter needle to the syringe. D. Tap the stem of the ampule. E. Wrap the stem of the ampule with a sterile gauze pad.

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

Explanation

A. Scrub the stem of the ampule with an antimicrobial wipe. This is not necessary because the stem of the ampule is broken and is not typically touched with hands or contaminated. The main concern is to prevent any glass from falling into the medication.

B. Break the stem of the ampule away from the body. Breaking the stem away from the body helps to prevent any shards of glass from falling into the medication or causing injury.

C. Attach a filter needle to the syringe. A filter needle is used to prevent any glass particles from entering the syringe when drawing up the medication from an ampule.

D. Tap the stem of the ampule. Tapping the stem may help remove any bubbles but is not a standard practice in ampule preparation.

E. Wrap the stem of the ampule with a sterile gauze pad. Wrapping the stem with a sterile gauze pad provides protection from glass shards and helps prevent injury when breaking the ampule.

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The nurse is caring for a client with a terminal illness who has become pulseless. The code status for the client is unknown to the nurse and a hospital emergency response is called. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who reports daytime drowsiness. The client states, "My partner says my snoring is getting louder and it sometimes wakes me up." The nurse should further assess the client for which of the following?

Correct Answer is A

Explanation

The nurse is preparing a prescribed medication for a client from an ampule. Which of the following actions should the nurse take? Select all that apply.

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

Explanation

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