A client with lung cancer is receiving hospice care at an inpatient facility. Currently, the client's heart rate is 46 beats/minute, respirations are 10 breaths/minute, and the blood pressure is 73/49 mm Hg. The client tells the practical nurse (PN) that, "I am ready to make peace with God." Which intervention should the PN implement?
Contact the facility's chaplain for spiritual support.
Encourage client to remain hopeful for recovery.
Invite family and staff to pray at the client's bedside.
Ask family to request that the client's clergy visit.
The Correct Answer is A
A. Contact the facility's chaplain for spiritual support: This addresses the client's expressed spiritual need, consistent with holistic end-of-life care.
B. Encourage client to remain hopeful for recovery: Inappropriate in hospice care; focus should be on comfort and emotional needs, not unrealistic recovery goals.
C. Invite family and staff to pray at the client's bedside: This may be supportive, but should only be done if the client requests it.
D. Ask family to request that the client's clergy visit: This puts responsibility on family instead of directly meeting the client's stated wish.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Replace the umbilical cord clamp close to the infant's body: Cord clamping helps prevent umbilical bleeding, but does not address the systemic clotting deficiency common in newborns.
B. Provide the first oral fluids using formula: Feeding is important but does not prevent bleeding.
C. Administer phytonadione intramuscularly: Vitamin K (phytonadione) is given shortly after birth to prevent hemorrhagic disease of the newborn, as neonates have immature gut flora and cannot synthesize enough vitamin K for clotting.
D. Use the axillary method to obtain core body temperature: Temperature monitoring is important but unrelated to bleeding prevention.
Correct Answer is B
Explanation
A. Collect ear drainage for culture:
May be indicated if ordered, but not routine before instillation of drops.
B. Warm the drops to room temperature:
Prevents dizziness or nausea from instilling cold drops and promotes comfort.
C. Don sterile gloves to instill the drops:
Clean technique is used for otic medications, not sterile gloves.
D. Insert the dropper into the ear canal:
Risk of trauma and contamination; dropper should remain above canal opening.
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