The client has a documented advance health care directive that indicates that no resuscitative measures should be employed in the event of a respiratory or cardiac arrest
The client begins to exhibit severe dyspnea and air hunger and says, "Please do something, I can't breathe." What action should be taken by the nurse?
1. Offer the client comfort measures until death occurs.
2. Call the client's physician for direction.
3. Initiate resuscitative measures.
4. Check the medical record to ascertain the terms of the directive.
Correct Answer: 3
Rationale 1: Just offering comfort measures until the client dies is ignoring the client's wishes.
Rationale 2: There is no need to call the physician for direction, as the client has clearly given the nurse direction.
Rationale 3: This client has the right to change decisions about resuscitation, and has asked for help. The nurse should initiate resuscitative measures.
Rationale 4: The nurse should have already known the terms of the directive and would not have time to seek clarification at this point.
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