A client with end-stage renal disease, oxygen-dependent chronic obstructive pulmonary disease (COPD), and a Do Not Resuscitate (DNR) code status is admitted to the medical floor for COPD exacerbation. The nurse walks into the room and finds that the client is not breathing. What should the nurse do first?

Question

Quizplus · Accepted Answer

The nurse has a medical order stating that the client should not be resuscitated. Therefore, the appropriate first action is to assess the apical pulse. Then the nurse should call the HCP. If the client's family members are present, the nurse should explain what is happening and make sure that they have support. (Option A) Activating the code system is not appropriate as this client has an order to withhold resuscitation. (Option B) The nurse should assess the client and then call the HCP. A stat page is not needed when the client is DNR. (Option D) Measuring the blood pressure is not appropriate if this client has stopped breathing. Checking an apical or central pulse would be appropriate after noticing that the client is not breathing. Educational objective: A DNR order requires the nurse to withhold resuscitation in the event of a cardiac or respiratory arrest. If an event occurs, the nurse should assess for breathing and check the central or apical pulse. After performing these actions, the nurse should call the HCP to confirm the death.

A Client with End-Stage Renal Disease, Oxygen-Dependent Chronic Obstructive Pulmonary