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A nurse is caring for a client who has gone into cardiac arrest. The client's chart indicates refusal of life-sustaining measures in a living will signed 10 years ago, but a do-not-resuscitate (DNR) prescription has not been written by the provider. Which of the following actions by the nurse is appropriate?

A.

Contact the provider for instructions regarding a DNR.

B.

Consult with the client's family regarding resuscitation efforts.

C.

Comply with the living will and let the client expire naturally.

D.

Call a code because a DNR prescription has not been written.

Answer and Explanation

The Correct Answer is D

A. Contacting the provider for instructions could delay immediate resuscitative efforts, which are required in the absence of a DNR order.  

 

B. Consulting with the client’s family may not be effective in an emergency, as the living will is a legal document, and family members cannot override it without a DNR order.  

 

C. Complying with the living will and letting the client expire naturally would be inappropriate without a formal DNR order in place.  

 

D. Calling a code is the correct action because, legally, resuscitative efforts must be initiated in the absence of a written DNR order from the provider, despite the existence of a living will.


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View Related questions

Correct Answer is A

Explanation

A. Obtaining the client's capillary blood glucose level is the first action because it determines the appropriate timing and dosage of insulin administration, ensuring safe and effective diabetes management.

B. Administering prescribed insulin should occur after assessing the client's blood glucose level to avoid the risk of hypoglycemia or hyperglycemia.

C. Providing the client's breakfast is important but should only occur after assessing blood glucose and administering insulin as needed to maintain stable glucose levels.

D. Checking the calibration of the glucometer is essential for accurate readings but does not directly address the immediate need to assess the client's glucose level.

Correct Answer is D

Explanation

A. While paranoia in a client with dementia can be concerning, it is not immediately life-threatening and may require additional support or medication adjustments.

B. Itching after receiving a dose of cefaclor may indicate an allergic reaction, but further assessment would be needed to determine the severity.

C. A weight gain of 1 kg (2.2 lb) in a client with heart failure should be monitored, but it is not an immediate concern unless accompanied by other symptoms of fluid overload.

D. The progression of a pressure ulcer from stage II to stage III indicates a worsening condition that requires urgent intervention to prevent further complications and potential infection, making it the highest priority to report.

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