A family requested a visit from a hospice nurse as they think the client appears to be nearing the end of life. 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).
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Entering the occurrence after the 1400 notes and identifying it as a “late entry” is an acceptable practice but may not provide sufficient clarity regarding the timing of the documentation.
Choice B rationale
Requesting removal initiated by the Health Information Manager is not necessary in this scenario. The focus should be on accurately documenting the missed occurrence rather than removing previously entered documentation.
Choice C rationale
Creating an electronic correction after 1400 notes are officially unlocked implies that there was an error in the original documentation. Since the issue here is not correcting an error but rather adding missed documentation, creating a correction may not be appropriate.
Choice D rationale
Making an electronic addendum following the 1400 documentation allows the nurse to add additional information to the chart without altering the original entry. This approach maintains the integrity of the original documentation while clearly indicating that the 0900 occurrence was added after the fact.
Correct Answer is ["A","C","D","E","F"]
Explanation
Choice A rationale
Double-checking all dosage calculations is a critical step in preventing medication errors. This ensures that the correct dose is administered and helps avoid potentially harmful mistakes.
Choice B rationale
The option “nusually large or small doses” seems to be a typographical error and does not provide a clear action to prevent medication errors. Therefore, it is not considered a correct choice.
Choice C rationale
Comparing the medication label to the order is essential to ensure that the correct medication is being administered. This step helps verify that the medication matches the provider’s prescription.
Choice D rationale
Using at least two client identifiers before administering a dose is a standard safety practice to confirm the client’s identity and prevent administering medication to the wrong person.
Choice E rationale
Involving and educating clients in medication administration can help prevent errors by ensuring that clients are aware of their medications and can alert the nurse to any discrepancies or concerns.
Choice F rationale
Documenting all medication in the electronic record as soon as it is given is crucial for maintaining accurate records and ensuring that all healthcare providers have up-to-date information about the client’s medication administration.
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