A hospice client is being cared for by the nurse at home. The client begins to experience changes in respirations, coughing and becoming increasingly restless. Based on these clinical manifestations, the nurse would implement which of the following interventions? (SELECT ALL THAT APPLY) ( Medical orders are active for each intervention that would require a medical order.)

Call for transportation to the hospital

Initiate low-flow oxygen per nasal cannula

Provide relief from pain and from other distressing symptoms

Place the bed in semi-Fowler's position

Administer anti-anxiety medications as needed

Answer and Explanation

Correct Answer : C,D

C. Providing relief from pain and other distressing symptoms is a fundamental aspect of hospice care. The nurse should assess the client's pain level and other symptoms such as dyspnea, coughing, and restlessness, and intervene accordingly. This may involve administering analgesics, antitussives, or other medications as appropriate to alleviate discomfort and promote comfort and quality of life.
D. Placing the bed in semi-Fowler's position (with the head of the bed elevated) can help improve respiratory mechanics, ease breathing, and reduce respiratory distress in clients experiencing dyspnea. This position allows for better lung expansion and can facilitate the drainage of respiratory secretions, thereby promoting comfort and alleviating symptoms. This intervention does not typically require a medical order and can be implemented by the nurse based on clinical assessment.
A. Calling for transportation to the hospital may not be necessary or appropriate in this situation, especially considering that the client is under hospice care and experiencing changes in respiratory status and restlessness, which could be indicative of end-of-life processes. Hospice care focuses on providing comfort and symptom management in the home setting, and hospitalization may not align with the client's goals of care at this stage.
B. Initiating low-flow oxygen per nasal cannula may be appropriate to provide comfort and relieve hypoxia if the client is experiencing respiratory distress. However, this intervention would typically require a medical order, as oxygen therapy should be prescribed based on assessment findings and clinical indications.
E. Administering anti-anxiety medications may be considered if the client is experiencing significant anxiety or agitation that is distressing and impacting their comfort. However, the decision to administer anti-anxiety medications should be based on thorough assessment and consideration of the client's overall condition, goals of care, and potential risks and benefits. This intervention would typically require a medical order.

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Correct Answer is D

Explanation

D. 0.9% sodium chloride (0.9% NaCl): This solution, also known as normal saline, is isotonic and contains the same concentration of sodium as extracellular fluid. It is the most appropriate choice for initial fluid resuscitation in hypovolemia due to severe bleeding because it rapidly expands intravascular volume, replaces sodium losses, and helps restore circulating blood volume.
A. This solution contains dextrose (glucose) and a small amount of sodium chloride. It provides some glucose for energy but has a lower sodium concentration compared to isotonic solutions like normal saline. While it may be used in certain situations, such as to provide maintenance fluids or correct mild dehydration, it is not the first choice for fluid resuscitation in hypovolemia due to severe bleeding because it does not adequately replace lost volume.
B. 3% sodium chloride (3% NaCl): This solution is hypertonic and has a high sodium concentration. It is not typically used for initial fluid resuscitation in hypovolemia due to severe bleeding. Hypertonic saline solutions like 3% NaCl are more commonly used in specific situations such as severe hyponatremia or cerebral edema.
C. 5% dextrose in water (D5W): This solution contains only dextrose and water and is isotonic until the dextrose is metabolized, after which it becomes hypotonic. D5W is not suitable for fluid resuscitation in hypovolemia due to severe bleeding because it does not provide adequate sodium or volume replacement.

A. is scheduled for a biopsy. B. needs to relocate to an assisted-living facility. C. researches and understands the stressor. D. Is experiencing a number of stressors at the same time.

Correct Answer is D

Explanation

D. Experiencing multiple stressors simultaneously can overwhelm an individual's coping resources and make it more difficult to effectively manage stress. Coping with multiple stressors can lead to feelings of being overwhelmed, heightened anxiety, and decreased ability to cope with each stressor individually.
A. Undergoing a biopsy can be a stressful experience due to uncertainty about the results and fear of the procedure itself. However, the level of difficulty in coping with this stressor can vary among individuals depending on factors such as their coping mechanisms, social support, and previous experiences with medical procedures.
B. Relocating to an assisted-living facility can be a significant life transition, involving changes in living arrangements, loss of independence, and adjustment to a new environment. This stressor can be particularly challenging for individuals who have strong attachments to their current living situation or who are facing health-related issues that necessitate the move.
C. Understanding and researching the stressor can sometimes help individuals cope better by providing knowledge and a sense of control. However, this does not necessarily make coping with the stressor easier, especially if the stressor itself is significant or if the individual lacks adequate support or resources to manage it effectively.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted with hypovolemia due to severe bleeding. Which Intravenous fluid does the nurse anticipate using to replace fluid losses?

Correct Answer is D

Explanation

The nurse recognizes that the patient who might have the most difficult time coping with a stressor is the one who:

Correct Answer is D

Explanation

The nurse recognizes that chronic stress can lead to a variety of illnesses in a patient. This is primarily because:

A client requires a medication immediately. Which abbreviation would be written in the physician's order for this medication?

The nurse assessing a client's intravenous catheter site suspects a phlebitis based on which clinical findings?

For an arterial blood gas (ABG) to have full compensation, which of the following statements is correct?

A nurse discovers that the physician has prescribed a higher than recommended dose of a medication for a client. Which is the most appropriate action for the nurse to take?

The home care nurse is assessing a client's abdomen 4 weeks after a colostomy in the descending colon was created. What are the expected findings of the a healthy client's abdominal assessment? (SELECT ALL THAT APPLY)

A nurse caring for a client who has a peripheral intravenous saline lock understands that its purpose is to: