A client with end stage metastatic cancer has a living will stating no extraordinary measures are to be taken as death approaches, and the healthcare provider writes a "Do Not Resuscitate" (DNR) prescription. When the client begins to take gasping breaths, the nurse determines the client's oxygen saturation is 85%. Which action should the nurse implement?

Manually ventilate using a bag valve mask apparatus.

Determine if client wishes have changed.

Report client's status to the healthcare provider.

Administer oxygen via a nasal cannula.

Answer and Explanation

The Correct Answer is D

A.   Using a bag valve mask (BVM) to manually ventilate the client would be considered an extraordinary measure, which conflicts with the client's living will stating no extraordinary measures should be taken.
B.   While it's essential to ensure that the client's current wishes are respected, the client is likely unable to communicate effectively due to their condition. If the client were able to express their wishes at this stage, it might be important to confirm, but given the client's living will and the established DNR order, the primary focus should be on adhering to these documents.
C.   Reporting the client's status to the healthcare provider is important to ensure that the provider is informed about the client’s current condition and can offer guidance or make necessary adjustments in the care plan. However, if the healthcare provider is already aware of the client's living will and DNR order, this step may be secondary to following the existing orders.
D.   Administering supplemental oxygen via a nasal cannula is a palliative measure that can provide comfort without being considered an extraordinary measure. It aligns with the goal of providing symptom relief and comfort care rather than resuscitation or life-extending interventions.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. Knowing the consistency of the prescribed diet (e.g., pureed, mechanical soft, or regular) is important for planning the feeding process and ensuring that the diet meets the client's needs and restrictions. However, this information is secondary to assessing the client’s ability to safely chew and swallow.
B. While reviewing current medications is important for understanding potential drug interactions, side effects, or dietary restrictions, it is not the most immediate concern before feeding. Medications can influence appetite and digestion, but the priority is ensuring the client can safely handle the food.
C. This is the most critical information to obtain before feeding a debilitated client. Assessing the client's ability to chew and swallow helps prevent complications such as aspiration, choking, or aspiration pneumonia. The nurse should ensure that the client can safely manage the food given to them and that their swallowing mechanisms are functioning adequately.
D. While monitoring the respiratory rate and lung sounds is important for overall health assessment, it is not the immediate priority before starting a feeding session. However, it is important to monitor for signs of aspiration during and after feeding, as compromised swallowing can lead to aspiration pneumonia.

A. Medical diagnoses. B. Age and gender. C. Developmental stage. D. Functional capacity.

Correct Answer is D

Explanation

A. While medical diagnoses can influence the type of care a client needs, functional capacity is the most important factor when determining the best living environment.
B. Age and gender can be factors to consider, but they are not as important as functional capacity. For example, an older adult with a high level of functional independence may be able to live independently, even if they are elderly.
C. This is not relevant to the decision of where an older adult client should live.
D. The client's functional capacity is the most important factor to consider when determining the best living environment. If the client requires significant assistance with ADLs, a nursing home or assisted living facility may be the most appropriate option.

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Naxlex Comprehensive Predictor Exams

The nurse is preparing to feed a newly admitted older adult client who is debilitated, but is able to respond to most commands. Before starting to feed the client, which information is most important for the nurse to obtain?

Correct Answer is C

Explanation

In assisting the family of an older adult client to determine the best living environment for the client, which factor is most important for the nurse to consider?

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?

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

An older client is being admitted to a rehabilitation unit from a medical-surgical unit following a left hip replacement. When reviewing the client's prescribed medications, which intervention should the nurse implement first?

An older adult client residing in a long-term care facility has become disoriented and suddenly develops urinary incontinence. Which intervention should the nurse implement?

When preparing to change a client's sterile dressing, the nurse pours sterile solution over a package of gauze pads as seen in the picture. Which should the nurse do next?

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?