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 ["5"]

Explanation

Step 1: Calculate the volume to administer. 200 mg ÷ (1000 mg ÷ 25 mL) = 200 mg ÷ 40 mg/mL = 5 mL The nurse should administer 5 mL.

A. 0800. B. 1000. C. 1200. D. 1400. E. 1600. F. 1800. G. 2000.

Correct Answer is ["A","C","E","G"]

Explanation

Choice A rationale
Measuring vital signs at 0800 is a standard practice in many healthcare settings to establish a baseline for the day.
Choice B rationale
Measuring vital signs at 1000 is not typically a standard time unless there is a specific clinical indication.
Choice C rationale
Measuring vital signs at 1200 helps monitor the client’s status around midday and can be important for assessing the effects of morning medications or treatments.
Choice D rationale
Measuring vital signs at 1400 is not typically a standard time unless there is a specific clinical indication.
Choice E rationale
Measuring vital signs at 1600 helps monitor the client’s status in the afternoon and can be important for assessing the effects of afternoon medications or treatments.
Choice F rationale
Measuring vital signs at 1800 is not typically a standard time unless there is a specific clinical indication.
Choice G rationale
Measuring vital signs at 2000 helps monitor the client’s status in the evening and can be important for assessing the effects of evening medications or treatments.

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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

The healthcare provider prescribes streptomycin 200 mg IM every 12 hours. The vial is labeled, “Streptomycin 1 gram/25.”. How many milliliters should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)

Correct Answer is ["5"]

Explanation

What times should the nurse measure vital signs? Select all that apply.

Correct Answer is ["A","C","E","G"]

Explanation

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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?