Question

The nurse receives report on the client who had an extensive stroke and is aphasic with a do not resuscitate (DNR) prescription. Initial assessment reveals pulse is 102 beats/min, respirations 28 breaths/min, BP 82/42 mm Hg, temperature 96.7°F (35.9°C) orally, and O 2 saturation of 84% on 4 L/min oxygen by nasal cannula. Which actions will the nurse implement based on these data? (Select all that apply.)

A) Assess for advance directives.
B) Contact the health care provider.
C) Confirm the DNR prescription.
D) Contact the family about impending death.
E) Provide pain medication.

Answer 1

The nurse should contact the health care provider, confirm the DNR prescription, and assess for advance directives. Contacting the family about impending death and administering pain medication may not be immediately appropriate until further steps are taken and more information is available.

Step-by-step explanation:

Based on the data provided, the nurse should implement the following actions:

• Contact the health care provider because the vital signs indicate potential shock and may require immediate medical intervention to address hypotension and hypoxemia.
• Confirm the DNR prescription to ensure that any actions taken align with the patient's and family's wishes regarding resuscitation efforts.
• Assess for advance directives, which may have additional information regarding the patient's treatment preferences beyond the DNR.

The nurse should not contact the family about impending death until all the necessary clinical information is gathered and the health care provider is consulted. Providing pain medication may be appropriate, but the priority is to stabilize the patient's vital signs and ensure that actions align with the patient's wishes as documented in the advance directives and DNR order.