A client who is terminally ill has an advance directive that stipulates no resuscitative measures are to be taken. The client's death is imminent and the family is in the client's room. The client is currently exhibiting Cheyne-Stokes respirations and has a blood pressure of 60/30 mm Hg. Which is the priority nursing action?

Allow privacy for the family and client to express their feelings to one another.

Apply an automatic blood pressure cuff and take readings every 15 minutes.

Teach the client's family how to use an oral suction device to clear the airway.

Elevate the head of the client's bed and apply oxygen using a face mask.

Answer and Explanation

The Correct Answer is A

A.   Allowing privacy for the family and client is a compassionate and appropriate action, especially as the client's death is imminent. This respects the client's wishes and provides a supportive environment for the family to process their emotions and say their goodbyes.
B.   Continuously measuring blood pressure in this scenario is less appropriate because the client is in the final stages of life and their focus should be on comfort rather than monitoring vital signs. Frequent blood pressure measurements may be distressing for the family and do not align with the goals of end- of-life care, which prioritize comfort and dignity.
C.   Teaching the family to use an oral suction device is not appropriate at this stage because the client is actively dying, and such interventions are not typically useful or necessary in end-of-life care. The focus should be on providing comfort rather than invasive procedures or teaching new skills to family members.
D.   Applying oxygen and elevating the head of the bed can be appropriate interventions for clients experiencing respiratory distress; however, this may conflict with the advance directive if the directive explicitly states no resuscitative measures

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Correct Answer is A

Explanation

A. Decreasing the time intervals between toileting can help prevent accidents by ensuring that the resident has more frequent opportunities to use the bathroom. Encouraging Kegel exercises (pelvic floor exercises) can help strengthen the muscles responsible for controlling urination and may improve incontinence.
B. Using disposable undergarments and changing them frequently can help manage incontinence and protect the skin from irritation and breakdown. However, this intervention primarily addresses the symptoms of incontinence rather than the underlying causes.
C. Limiting fluid intake in the evening can reduce the likelihood of nocturia (nighttime urination) and may help in managing urinary incontinence. However, reducing fluid intake can also lead to dehydration and other health issues.
D. Offering emotional support and reassurance is important for the resident’s mental well-being and can help reduce anxiety related to incontinence. Understanding that urinary incontinence is common among older adults can be comforting, but this approach alone does not address the practical management of the condition or contribute to improving urinary control.

A. Decrease the rate of the feeding by half. B. Observe for an allergic reaction to the formula. C. Hang a new bag of the enteral formula. D. Stop the tube feeding and assess the client.

Correct Answer is D

Explanation

A. Decreasing the rate of the feeding might be a consideration if the feeding was too rapid, but it is not the immediate priority if aspiration is suspected.
B. While it is important to monitor for allergic reactions to enteral formulas, this is not the immediate concern if aspiration is suspected. Allergic reactions would typically present with symptoms such as rash, itching, or gastrointestinal distress, and not immediately after aspiration.
C. Hanging a new bag of enteral formula is not an appropriate action if aspiration is suspected. The
priority is to ensure the client’s safety and address any complications that may arise from the aspiration, such as aspiration pneumonia.
D. Stopping the tube feeding and assessing the client is the most appropriate initial action if aspiration is suspected. Immediate assessment is necessary to determine if the client is experiencing signs of aspiration, such as coughing, wheezing, difficulty breathing, or changes in consciousness.

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Naxlex Comprehensive Predictor Exams

An older female resident of a long-term care facility is experiencing frequent episodes of urinary incontinence. Which intervention is best for the nurse to implement with this client?

Correct Answer is A

Explanation

A client with a gastrostomy tube is receiving a continuous feeding, and the nurse suspects that the client has aspirated some of the feeding. Which action should the nurse take?

Correct Answer is D

Explanation

When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next?

The nurse prepares to instill an adolescent client's ear drops as seen in the picture. Which should the nurse do next?

Which assessment is most important for the nurse to perform prior to the application of a heating pad?

A client who has a continuous tube feeding develops a fever and reports experiencing dyspnea. Which action should the nurse implement?

An older adult client's skin feels warm and the client has a temperature of 101.2° F (38.4° C). The nurse further assesses that the client has a reddened tongue, dry mucous membranes, and inelastic skin turgor. Which serum laboratory value should the nurse monitor most closely?

Prior to receiving a 120 mL hypertonic enema, an ambulatory female client tells the nurse that she does not believe that she can walk all the way to the bathroom without expelling the enema. Which intervention is best for the nurse to implement?

The nurse finds a confused client wandering in the hallway during the night. Which actions should the nurse implement? Select all that apply.