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Difficulty: HardLegal and Ethical Practice

A practical nurse (PN) is caring for a client with end-stage heart failure who is alert, oriented, and has a signed, legally valid "Do Not Resuscitate" (DNR) order in the medical record. The client suddenly develops severe respiratory distress and profound cyanosis. The client's spouse panics and yells, "Please do everything you can to save them! Ignore that DNR paper!" The client is gasping and unable to speak but firmly shakes their head 'no' and pushes the nurse's hands away when approached with a supplemental oxygen mask. Which action is legally and ethically appropriate for the PN?

  1. Respect the client's documented DNR order and current nonverbal refusal of treatment, provide emotional support, and immediately notify the charge nurse.Answer
  2. B
    Explain the complex medical prognosis to the spouse to help them understand why the DNR was signed and obtain their consent to withhold care.
  3. C
    Secure the client's wrists gently to apply the oxygen mask, prioritizing essential airway stabilization until the primary healthcare provider can be reached.
  4. D
    Administer a prescribed as-needed (PRN) intravenous (IV) push opioid to alleviate the client's severe air hunger and reduce their resistance to care.

Answer

The legally and ethically correct action is to respect the client's documented DNR and nonverbal refusal of the oxygen mask, while maintaining presence to provide comfort and escalating the situation to the charge nurse.
The correct action upholds the ethical principle of autonomy and the legal requirement to honor a competent client's refusal of treatment. Even though the client cannot speak due to respiratory distress, they are alert and their nonverbal refusal (pushing the mask away, shaking their head) is valid. A valid DNR order further supports withholding resuscitative efforts. The spouse cannot legally override a competent client's refusal. By remaining with the client and notifying the charge nurse, the PN provides safe, ethical care within their scope of practice.

Step-by-Step Solution

1
Assess the client's competency and current wishes.
The client is alert, oriented, and actively refusing the oxygen mask through clear nonverbal communication.
A competent client's immediate, expressed wishes take precedence over family demands and previous directives.
2
Evaluate the legal validity of the spouse's demand.
The spouse's demand is legally invalid in this context.
A healthcare proxy or family member cannot override the decisions of a client who is currently competent, nor can they arbitrarily revoke a valid DNR against the client's wishes.
3
Determine the appropriate scope of practice for the PN.
The PN must honor the refusal, avoid forceful restraints or out-of-scope IV push medications, and seek RN assistance.
The PN must practice within legal boundaries, which prohibits battery (forcing treatment), out-of-scope tasks, and stepping into the provider's role of delivering complex medical prognoses.

Key Concept

Client Autonomy, Advance Directives, and PN Scope of Practice
Estimated Time:1m 30s
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Topics

Legal and Ethical Practice

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