A male client is admitted with difficulty breathing related to a recent diagnosis of metastatic lung cancer. He tells the nurse that he does not want to be hooked up to any machines. His vital signs are heart rate 120 beats/minute, blood pressure 98/50 mm Hg, respirations 30 breaths/minute, and oxygen saturation 88%. Which action should the nurse take?
Obtain the client's legal records for power of attorney.
Give analgesic medications as needed (PRN).
Discontinue the intravenous infusion.
Ask the palliative care team to speak with the client.
The Correct Answer is D
Choice A Reason: This is not the first priority because it does not address the client's immediate needs. The nurse should obtain the client's legal records for power of attorney, but this can be done later.
Choice B Reason: This is a good action because it helps relieve the client's pain and discomfort. The nurse should give analgesic medications as needed (PRN), but this is not enough to meet the client's holistic needs.
Choice C Reason: This is not an appropriate action because it may cause harm to the client. The nurse should not discontinue the intravenous infusion without a valid reason and a healthcare provider's order.
Choice D Reason: This is the best action because it respects the client's wishes and provides him with quality end-of-life care. The nurse should ask the palliative care team to speak with the client and offer him emotional, spiritual, and physical support.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason: This is the best action because it describes the current situation of the client and alerts the family to a possible change in the client's status. The nurse should provide the most relevant and urgent information first using the SBAR communication.
Choice B Reason: This is not the first action because it does not address the current situation of the client. The nurse should verify the client's healthcare power of attorney, but this is not a priority at this time.
Choice C Reason: This is not the first action because it does not explain the cause of the client's confusion. The nurse should review the client's medications and assess for any adverse effects, but this is not a priority at this time.
Choice D Reason: This is not the first action because it provides background information that is not directly related to the current situation of the client. The nurse should give a brief history of the client's admission, but this can be done later.
Correct Answer is ["B","C"]
Explanation
Choice A Reason: Identifying locations of skin lesions on a newly admitted client is a nursing assessment that requires clinical judgment and cannot be delegated to the UAP.
Choice B Reason: Emptying the ostomy bag for a client with a temporary colostomy is a routine task that does not require clinical judgment and can be delegated to the UAP.
Choice C Reason: Providing a complete bed bath for a comatose client is a routine task that does not require clinical judgment and can be delegated to the UAP.
Choice D Reason: Performing foot care including toenail trimming and heel care is a nursing intervention that requires clinical judgment and cannot be delegated to the UAP. The UAP may cause injury or infection to the client's feet, especially if the client has diabetes or peripheral vascular disease.
Choice E Reason: Giving mouth care to an elderly client who has a tracheostomy is a nursing intervention that requires clinical judgment and cannot be delegated to the UAP. The UAP may cause trauma or aspiration to the client's trachea, especially if the client has poor oral hygiene or respiratory secretions.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today