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 A

Explanation

A. "STAT" stands for "immediately" or "at once" in medical terminology. When a medication order is marked as STAT, it means that the medication should be administered as soon as possible, without delay. This abbreviation is used for urgent situations where the medication needs to be given promptly.
B. "PRN" stands for "pro re nata," which translates to "as needed" in Latin. When a medication order is marked as PRN, it means that the medication should be administered as required based on the patient's needs or symptoms. The timing of administration is not fixed but depends on specific conditions or situations, such as pain or nausea.
C. "TID" stands for "ter in die," which translates to "three times a day" in Latin. When a medication order is marked as TID, it means that the medication should be administered three times daily, at regular intervals throughout the day.
D. "QID" stands for "quater in die," which translates to "four times a day" in Latin. When a medication order is marked as QID, it means that the medication should be administered four times daily, at regular intervals throughout the day.

A. set my bedroom temperature at 65 degrees at night." B. like to take a long walk at about 3:00 PM every day." C. used to pay my bills in bed. but I don't anymore." D. drink a few scotch and sodas while I watch TV at night before I go to sleep."

Correct Answer is D

Explanation

D. Consuming alcoholic beverages, especially close to bedtime, can disrupt sleep patterns and exacerbate insomnia. While alcohol may initially have a sedative effect and induce drowsiness, it can lead to fragmented and poor-quality sleep later in the night, resulting in worsened insomnia symptoms. Therefore, this statement indicates a need for further education by the nurse regarding the negative impact of alcohol consumption on sleep and the importance of avoiding alcohol before bedtime to improve sleep quality.
A. Keeping the bedroom cool (around 65 degrees Fahrenheit) is generally recommended for promoting sleep because a cooler temperature can help facilitate the body's natural temperature drop, which occurs during sleep onset.
B. Engaging in regular physical activity, such as taking a long walk during the day, can be beneficial for promoting better sleep. Physical activity during the day can help regulate the sleep-wake cycle, reduce stress, and improve overall sleep quality. Therefore, this statement reflects a positive sleep hygiene practice and does not indicate a need for further education.
C. This statement suggests an understanding of the importance of associating the bed with sleep and avoiding activities that may interfere with sleep, such as paying bills or working in bed. Maintaining the bed as a place primarily for sleep and intimacy can help condition the mind and body to associate the bed with relaxation and sleep.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is A

Explanation

Which statement made by a client experiencing insomnia indicates a need for further education by the nurse? "I

Correct Answer is D

Explanation

A client is admitted with a suspected opioid overdose and a respiratory rate of 6 breaths per minute. Which of the following data would the nurse anticipate? (SELECT ALL THAT APPLY)

How can teaching be best provided to a client who has a different primary language than the nurse?

The nurse is performing post-mortem care on a client who has just died. What nursing care should be given priority?

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

The nurse has finished providing a tube feeding to a client. What should the nurse document about this procedure? (SELECT ALL THAT APPLY)

A nurse is caring for a client who is newly diagnosed with cancer. Which of the following nursing interventions to maximize successful coping to the treatment plan should the nurse initiate at this time? (SELECT ALL THAT APPLY)

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

The nurse knows the fecal output will be more solid from a stoma created from which area of the bowel?