A nurse enters a client's room and finds the client pulseless. The family has requested a do-not-resuscitate (DNR) order from the provider, but he has not written the order yet. Which of the following actions should the nurse take?
Call the provider for a stat DNR order.
Start CPR and call the emergency response team.
Seek immediate help from the risk manager.
Respect the family's wishes and do nothing.
The Correct Answer is B
Rationale:
A. There is no time to wait for a DNR order in an emergency; immediate action is needed.
B. Without a written DNR order, the nurse is legally and ethically obligated to initiate CPR and call the emergency response team to attempt to save the client’s life.
C. Contacting the risk manager is not an immediate action that would benefit the patient in this emergency situation.
D. The family’s wishes cannot be respected in this scenario without a formal DNR order in place; thus, the nurse must perform CPR.
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Correct Answer is A
Explanation
Rationale:
A. Clustering nursing activities helps to minimize interruptions, allowing the patient to have longer periods of uninterrupted rest, which is essential for recovery and reducing sensory disturbances from sleep deprivation.
B. Silencing alarms could compromise patient safety and is not recommended.
C. Administering sedatives or opioids should be done cautiously and is not a first-line approach for promoting sleep, especially if non-pharmacological methods can be effective.
D. While reducing nighttime assessments may help with sleep, it is not always feasible and should be balanced with the need for monitoring the patient’s condition.
Correct Answer is D
Explanation
Rationale:
A. Documentation of waveform values is important but does not directly enhance patient safety during monitoring.
B. Limiting the pressure tubing length can help maintain accuracy, but it is not the primary safety measure.
C. Zero referencing is crucial for accurate readings, but it must be done in conjunction with ensuring alarms are active.
D. Ensuring that alarm limits are turned on and appropriately set is the best safety measure to immediately alert the nurse to any critical changes in the patient's status.