During a home visit, the client with terminal cancer undergoes respiratory arrest. The client has agreed to a DNR (do not resuscitate) order; however, the spouse tells the nurse to call 911. What action should the nurse take?
1. Assess vital signs.
2. Call 911.
3. Start CPR.
4. Remind the spouse of the client's desires.
Correct Answer: 4
Rationale 1: Assessment of vital signs does not address the immediate situation.
Rationale 2: In the event of conflict between the client's desires and the family's wishes, the nurse, being the client's primary advocate, ensures that the client's rights and desires are upheld. This is a difficult situation, but the nurse is bound to the client's desires. Calling 911 would not support the client's desires.
Rationale 3: In the event of conflict between the client's desires and the family's wishes, the nurse, being the client's primary advocate, ensures that the client's rights and desires are upheld. This is a difficult situation, but the nurse is bound to the client's desires. Starting CPR would not support the client's desires.
Rationale 4: In the event of conflict between the client's desires and the family's wishes, the nurse, being the client's primary advocate, ensures that the client's rights and desires are upheld. This is a difficult situation, but the nurse is bound to the client's desires.
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