A client with a traumatic brain injury becomes progressively less responsive to stimuli. The client has a "Do Not Resuscitate" prescription, and the nurse observes that the unlicensed assistive personnel (UAP) has stopped turning the client from side to side as previously scheduled. Which action should the nurse take?
Explanation & Rationale
A. Even though the client has a "Do Not Resuscitate" (DNR) order, routine care such as turning the client to prevent complications (e.g., pressure ulcers) remains important. The nurse should ensure the UAP understands the need to continue positioning the client according to the care plan, as this is a preventive measure for comfort and overall care, not a resuscitative measure. B. Assume total care of the client to monitor neurologic function: Assuming total care may not be necessary, but providing guidance on comfort care measures is appropriate. C. Comfort care measures are important, but preventing complications such as pressure ulcers by turning the client is also part of providing comfort and care. Ceasing turning the client prematurely could lead to additional complications, which is not in the best interest of the patient. D. Assign a practical nurse to assist the UAP in turning the client: While additional assistance may be helpful, ensuring that comfort care measures are provided is the priority.