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 D

Explanation

A. While it is generally good practice to measure blood pressure in both arms for a comprehensive assessment, this is not the primary concern with hypocalcemia. Hypocalcemia primarily affects neuromuscular and cardiovascular systems, so while blood pressure monitoring is important, it does not directly address the critical symptoms associated with low calcium levels.
B. Assessing skin turgor is a useful practice for evaluating hydration status and skin elasticity but is not specifically related to the management or symptoms of hypocalcemia. In hypocalcemia, skin changes are not the most relevant concern compared to neuromuscular symptoms.
C. Hypocalcemia can increase the risk of bleeding and bruising due to impaired blood clotting mechanisms. Monitoring for bruising can be an important aspect of assessing the effects of low calcium levels on the client’s hemostatic function. Bruising can be a direct indicator of the impact of hypocalcemia on blood coagulation and is relevant to the clinical management of the condition.
D. Hypocalcemia can affect cardiac function, potentially leading to changes in heart rhythm and rate. Monitoring the rhythm of the pulse is crucial, as it can help identify arrhythmias or other cardiac disturbances associated with low calcium levels.

A. Reposition the dropper. B. Pull the auricle up and out. C. Visualize the ear drum. D. Administer the ear drops.

Correct Answer is B

Explanation

A. The dropper should already be positioned correctly, with the tip pointing toward the ear canal.
B. For adolescents and adults, the auricle (outer ear) should be pulled up and out to straighten the ear canal. This allows the ear drops to flow directly into the ear canal, avoiding the tympanic membrane (eardrum). Correctly positioning the auricle helps to prevent irritation and discomfort during ear drop administration.
C. While visualizing the eardrum is important for certain procedures, it's not necessary when administering ear drops.
D. The ear drops should be administered after the auricle is pulled up and out to ensure proper placement in the ear canal.

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Naxlex Comprehensive Predictor Exams

A client has a total serum calcium level of 7.0 mg/dL (1.75 mmol/L). Based on this information, which action is most important for the nurse to include while measuring the client's vital signs? Reference Range: Total Calcium (9 to 10.5 mg/dL (2.25 to 2.62 mmol/L)]

Correct Answer is D

Explanation

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

Correct Answer is B

Explanation

When establishing a therapeutic environment for an older adult client, which intervention is most important for the nurse to implement?

The nurse is assessing an older female client who was admitted to a long-term facility two days ago. The resident refuses to go to the dining room for meals and calls for help with all activities of daily living. Which nursing problem is best to include in this client's plan of care?

The nurse is performing a functional assessment for a client requiring nursing home care. During the client interview, which action should the nurse implement?

The nurse identifies the hospitalized client in which situation as being at highest risk for the development of a healthcare associated infection (HAI)?

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

While changing the dressing of a client who is immobile, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

The nurse has agreed to serve as a client's advocate at the meeting of the hospital ethics committee, which was called to address an ethical dilemma involving the client. To successfully represent the client, what action is essential for the nurse to take?

When assessing a client's pain, the nurse determines the location and intensity of the pain. To gather data about the quality of the pain, which action should the nurse take?