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. Sudden weight gain can indicate fluid retention, a common early sign of heart failure exacerbation. Prompt reporting allows for early intervention.
B. Nitroglycerin is used to treat chest pain, not specifically to prevent heart failure exacerbations.
C. Assessment of the apical pulse is important, but monitoring weight is more directly related to managing heart failure.
D. Compliance with diuretic therapy is important, but recognizing early signs of fluid retention, such as rapid weight gain, is crucial for preventing exacerbations.
Correct Answer is B
Explanation
Rationale:
A. Epinephrine is an important drug in resuscitation but is administered after defibrillation in the algorithm.
B. Defibrillation is the priority intervention for ventricular fibrillation, as it is the only treatment that can convert the heart rhythm back to a viable one.
C. Airway management is crucial, but in the context of ventricular fibrillation, defibrillation takes precedence to restore a life-sustaining rhythm.
D. Amiodarone is used in the treatment of refractory ventricular fibrillation, but it is not the immediate priority over defibrillation.