Documentation and Interprofessional Communication
Documentation and Interprofessional Communication ( 5 Questions)
A client is admitted to the hospital with a diagnosis of pneumonia. The nurse notes that the client has a do-not-resuscitate (DNR) order in their chart. Which action should the nurse take regarding the DNR order?
Review the DNR order with the client and their family to ensure their understanding and agreement. - This is an unnecessary action, as reviewing the DNR order with the client and their family implies that they may not have made an informed decision or that they may change their mind, which can be disrespectful or coercive. The nurse should assume that the client and their family have already discussed and agreed on the DNR order with the health care provider who wrote it, unless there is evidence of misunderstanding or disagreement.
Notify the health care provider of the DNR order and request a written confirmation. - This is an unnecessary action, as notifying
the health care provider of the DNR order and requesting a written confirmation implies that there may be a discrepancy or doubt about
the validity of the order, which can be disrespectful or suspicious. The nurse should assume that the health care provider who wrote
the DNR order has already obtained informed consent from the client and their family and has documented it appropriately, unless there is evidence of error or omission.
Document the DNR order in the nursing care plan and communicate it to other health care team members.
Rationale: The nurse should document the DNR order in the nursing care plan and communicate it to other health care team members, as this ensures that the client's wishes are respected and followed in the event of a cardiac or respiratory arrest. Documenting and communicating the DNR order also prevents unnecessary or unwanted interventions that may cause harm or distress to the client.
Initiate a palliative care consultation for the client and their family to discuss end-of-life care options. - This is an inappropriate action, as initiating a palliative care consultation for the client and their family implies that they have a terminal condition or a poor prognosis, which may not be true for clients with pneumonia who have a DNR order. The nurse should not assume that all clients with a DNR order need or want palliative care, unless they express an interest or a need for it.
Correct answer: C) Document the DNR order in the nursing care plan and communicate it to other health care team members.
Rationale: The nurse should document the DNR order in the nursing care plan and communicate it to other health care team members, as this ensures that the client's wishes are respected and followed in the event of a cardiac or respiratory arrest. Documenting and communicating the DNR order also prevents unnecessary or unwanted interventions that may cause harm or distress to the client.
Incorrect options:
A) Review the DNR order with the client and their family to ensure their understanding and agreement. - This is an unnecessary action, as reviewing the DNR order with the client and their family implies that they may not have made an informed decision or that they may change their mind, which can be disrespectful or coercive. The nurse should assume that the client and their family have already discussed and agreed on the DNR order with the health care provider who wrote it, unless there is evidence of misunderstanding or disagreement.
B) Notify the health care provider of the DNR order and request a written confirmation. - This is an unnecessary action, as notifying
the health care provider of the DNR order and requesting a written confirmation implies that there may be a discrepancy or doubt about
the validity of the order, which can be disrespectful or suspicious. The nurse should assume that the health care provider who wrote
the DNR order has already obtained informed consent from the client and their family and has documented it appropriately, unless there is evidence of error or omission.
D) Initiate a palliative care consultation for the client and their family to discuss end-of-life care options. - This is an inappropriate action, as initiating a palliative care consultation for the client and their family implies that they have a terminal condition or a poor prognosis, which may not be true for clients with pneumonia who have a DNR order. The nurse should not assume that all clients with a DNR order need or want palliative care, unless they express an interest or a need for it.