A 45-year-old client with breast cancer which has metastasized is receiving hospice care. The client is at home and the family is concerned about their loved one.

The nurse assesses the client.

Which of the following signs indicate that the client is near death?

Decreased muscle tone, relaxed jaw muscles, sagging mouth.

Urine output is clear yellow.

Altered breathing (apnea, labored or irregular breathing, Cheyne-Stokes pattern).

Congestion/increased pulmonary secretions; noisy respirations (death rattle). .

Answer and Explanation

Correct Answer : A,C,D

Choice A rationale
Decreased muscle tone, relaxed jaw muscles, and a sagging mouth are common signs that indicate a client is near death. These changes occur as the body begins to shut down and muscle control diminishes.
Choice B rationale
Clear yellow urine output is not typically associated with the end-of-life stage. As death approaches, urine output usually decreases and may become darker in color.
Choice C rationale
Altered breathing patterns, such as apnea, labored or irregular breathing, and Cheyne-Stokes respiration, are common signs that a client is nearing death. These changes in breathing patterns are due to the body’s decreasing ability to regulate respiratory function.
Choice D rationale
Congestion and increased pulmonary secretions, often referred to as the “death rattle,” are common signs that a client is near death. These noisy respirations occur as the body’s ability to clear secretions diminishes.

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Correct Answer is []

Explanation

The correct answer is Potential Condition:

A. Secretory diarrhea.

Actions to Take:

A. Collect stool for culture.

D. Make the client NPO.

Parameters to Monitor:

A. Heart rate.

B. Serum potassium.

Potential Condition A rationale:

Secretory diarrhea is characterized by large volumes of watery stool and can be caused by infections, toxins, or certain medications. It is important to identify the underlying cause to provide appropriate treatment. Potential Condition B rationale:

Steatorrhea is characterized by fatty stools and is typically associated with malabsorption syndromes. The client’s symptoms do not suggest this condition. Potential Condition C rationale:

Motility diarrhea is caused by rapid transit of stool through the intestines, often due to conditions like irritable bowel syndrome. The client’s symptoms are more consistent with secretory diarrhea. Potential Condition D rationale:

Osmotic diarrhea occurs when non-absorbable substances draw water into the intestines. The client’s symptoms are more indicative of secretory diarrhea. Action A rationale:

Collecting stool for culture helps identify any infectious agents that may be causing the diarrhea, allowing for targeted treatment. Action B rationale:

Starting a high-fiber diet is not appropriate for a client with acute diarrhea, as it may exacerbate symptoms. Action C rationale:

Administering an oral steroid is not indicated for the treatment of secretory diarrhea and may worsen the condition. Action D rationale:

Making the client NPO (nothing by mouth) helps to rest the gastrointestinal tract and reduce the severity of diarrhea. Parameter A rationale:

Monitoring heart rate is important as dehydration from diarrhea can lead to tachycardia. Parameter B rationale:

Monitoring serum potassium is crucial as diarrhea can lead to significant electrolyte imbalances, including hypokalemia. Parameter C rationale:

Monitoring respiratory rate is not directly related to the management of diarrhea. Parameter D rationale:

Monitoring urine sodium is not directly related to the management of diarrhea.

A. 2+ edema of fingers and hands. B. Capillary refill time is 2 seconds. C. Blood pressure is 142/88 mm Hg. D. Radial pulse volume is 3+.

Correct Answer is A

Explanation

Choice A rationale
Edema in the fingers and hands can affect the accuracy of a pulse oximeter reading. The swelling can interfere with the probe’s ability to detect the blood flow properly, leading to a falsely low oxygen saturation reading.
Choice B rationale
A capillary refill time of 2 seconds is considered normal and does not typically affect the accuracy of a pulse oximeter reading.
Choice C rationale
Blood pressure of 142/88 mm Hg, while elevated, does not directly impact the accuracy of a pulse oximeter reading.
Choice D rationale
A radial pulse volume of 3+ indicates a strong pulse, which should not interfere with the accuracy of a pulse oximeter reading.

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A 45-year-old client with breast cancer which has metastasized is receiving hospice care. The client is at home and the family is concerned about their loved one. The nurse assesses the client. Which of the following signs indicate that the client is near death?

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Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

The nurse attaches a pulse oximeter to a client’s finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

Correct Answer is A

Explanation

Which intervention is most important for the nurse to implement before leaving a postoperative client with severe obstructive sleep apnea (OSA) alone?

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The nurse enters a client’s room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?

A nurse is reviewing a client’s orders and notes the following: Vital signs every 4 hours, regular diet, Cefazolin 1g IV every 8 hours for 5 days, Metformin 1,000 mg PO every 12 hours, and point of care blood glucose check every 4 hours. Which action should the nurse take?

Patient Data Exhibits Review H and P, nurse’s notes, flow sheet, laboratory values, orders, and imaging studies. What times should the nurse measure vital signs? Select all that apply.

The nurse is demonstrating three-point gait crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior indicates that the client understands proper crutch walking?

A 45-year-old client with breast cancer which has metastasized is receiving hospice care. The client is at home and the family is concerned about their loved one.

The nurse assesses the client.

Which of the following signs indicate that the client is near death?