Try Naxlex NCLEX-RN (Free-Trial)

A nurse is caring for a 78-year-old patient with end-stage heart failure on contact precautions for MRSA. The patient is wearing a purple DNR bracelet and has an advance directive stating "comfort measures only." The patient's oxygen saturation drops to 85%, and the patient becomes increasingly short of breath. Which action should the nurse take first?

Don a gown and gloves, enter the room, and assess the patient's comfort level and provide oxygen and morphine as ordered

Call a Code Blue and initiate CPR per hospital protocol

Document the patient's condition

Contact the healthcare provider to discuss transferring the patient to the intensive care unit

Answer and Explanation

The Correct Answer is A

End-stage heart failure is progressive myocardial pump failure causing systemic hypoperfusion, pulmonary congestion, hypoxia, dyspnea, palliative care, DNR directives prioritizing symptom relief, comfort-focused management, and avoidance of life-prolonging interventions therapies.

Rationale:

A. In a patient with comfort measures only and active DNR status, priority is symptom relief rather than resuscitation. The nurse should assess dyspnea severity and provide prescribed oxygen and morphine. This aligns with palliative goals and MRSA precautions protocol adherence.

B. Calling a Code Blue violates DNR orders and advance directive specifying comfort-only care. CPR initiation is inappropriate in end-stage disease. This action disregards end-of-life wishes and exposes patient to unwanted aggressive resuscitation contrary to ethical palliative care principles standards violated.

C. Documenting condition alone is incomplete during acute respiratory distress. Hypoxia requires immediate symptom management in comfort care settings. Failure to intervene with oxygen or opioids neglects palliative intervention priorities and does not address respiratory distress urgency per comfort protocol guidelines.

D. Contacting healthcare provider for ICU transfer conflicts with advance directive specifying comfort-only care. Escalation to intensive care contradicts palliative goals and DNR status. Focus should remain on symptom relief rather than invasive life-prolonging interventions in terminal heart failure clinical priority.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["D","E"]

Explanation

Pediatric unilateral hearing reduction commonly results from external auditory canal obstruction leading to impaired sound wave transmission to the tympanic membrane, producing conductive hearing loss due to mechanical blockage rather than cochlear or neural dysfunction processes.

Rationale:

A. Cerumen impaction involves accumulation of hardened earwax obstructing the external auditory canal. It can reduce hearing but does not specifically describe a visible bright green object. This condition is common but does not confirm foreign material presence. Therefore it is not the best match here.

B. Presbycusis is age-related degenerative hearing loss affecting elderly patients due to cochlear hair cell degeneration. It does not occur in kindergarten-aged children. It is a bilateral progressive sensorineural process unrelated to acute unilateral obstruction or visible foreign object in ear canal.

C. Sensorineural hearing loss results from cochlear or vestibulocochlear nerve damage affecting sound processing. It is not caused by visible external objects in the ear canal. There is no mechanical obstruction visible on inspection. Therefore it does not match the clinical finding described.

D. Conductive hearing loss occurs when sound transmission is blocked in external or middle ear structures. A visible foreign object obstructing the canal directly prevents sound conduction. This produces unilateral hearing loss consistent with reported symptoms in pediatric patients.

E. Foreign body obstruction is presence of external object in ear canal causing mechanical blockage. Bright green object strongly indicates inserted material such as toy fragment. This leads to acute unilateral hearing loss and is common in children due to exploratory behavior.

A. Unilateral lymphadenopathy B. Goiter C. Cervical muscle spasm D. Tension pneumothorax on the right side

Correct Answer is D

Explanation

Tracheal deviation indicates a significant intrathoracic pressure imbalance resulting in mediastinal displacement due to severe pulmonary pathology, most commonly associated with tension pneumothorax, mediastinal shift, lung collapse, and hypoxia requiring emergency intervention oxygen resuscitation

Rationale:

A. Unilateral lymphadenopathy does not produce tracheal deviation because lymph node enlargement is confined to cervical chains. It does not alter intrathoracic pressure dynamics. Therefore it is not associated with mediastinal shift or acute airway compromise requiring emergency intervention clinically irrelevant

B. Goiter may cause anterior neck mass and rarely tracheal deviation when significantly enlarged. However deviation is typically gradual rather than acute. It is not associated with sudden mediastinal shift or life-threatening ventilation compromise requiring emergency decompression clinically progressive condition usually

C. Cervical muscle spasm may produce neck discomfort and limited range of motion but does not affect intrathoracic structures. It cannot cause tracheal deviation or mediastinal shift and is not associated with respiratory compromise or emergent airway pathology clinically benign condition

D. Tension pneumothorax on the right side causes increased intrapleural pressure leading to mediastinal shift away from affected lung. This results in tracheal deviation, reduced venous return, hypoxia, and rapid cardiopulmonary collapse requiring immediate decompression life threatening emergency condition requires intervention

View Question and Answer

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The kindergarten student tells the school nurse that she can't hear out of her left ear. The nurse inspects the ear canal and sees a bright green object. Which condition does the nurse suspect? Select all that apply.

Correct Answer is ["D","E"]

Explanation

During an assessment, the nurse notes a trachea that is deviated to the client's left side. Which condition is the most critical for the nurse to suspect and prioritize intervention for?

Correct Answer is D

Explanation

Which is NOT considered a risk for developing breast cancer?

The patient is standing 10 feet from the eye chart but can only read what a person with normal vision could see from 200 feet away. What does the nurse document about the patient's vision?

Which finding in the client's history will alert the nurse to the most likely cause of the sensorineural hearing loss?

The nurse counsels a female patient who has been diagnosed with a sexually transmitted infection (STI). Which interventions should the nurse promote? Select all that apply.

The nurse inspects the patient's eyes. Which condition is most concerning?

The nurse is preparing to assess a 2 year old child's ears. Which technique is appropriate for visualizing the tympanic membrane?

The nurse is treating a patient diagnosed with the beginning stages of open-angle glaucoma. Which assessment data support this diagnosis?

A nurse is receiving bedside shift report on four assigned patients. Using clinical judgment and priority-setting principles, which patient requires the nurse to assess first?