A nurse is caring for a client who is at the end of life.
Vital Signs:
Temperature 38.5° C (101.3° F),
Blood pressure 76/46 mm Hg,
Heart rate 112/min,
Respiratory rate 34/min, irregular,
Pulse oximetry 84% on 40% humidified face mask.
Which of the following 3 actions should the nurse plan to take?
Tell the client there is nobody else in the room.
Turn the client on their side.
Place a fan to blow lightly toward the client.
Administer an opioid narcotic to the client.
Provide deep nasotracheal suctioning for the client.
Correct Answer : B,C,D
A. Tell the client there is nobody else in the room: This action is not appropriate as it does not address the immediate clinical needs of the client. Providing comfort and managing symptoms is a priority at the end of life.
B. Turn the client on their side: This action helps in relieving pressure, preventing aspiration, and improving respiratory function, which is particularly beneficial when a client is experiencing irregular and shallow breathing.
C. Place a fan to blow lightly toward the client: A fan can help alleviate discomfort from labored breathing and provide a cooling effect, which can be soothing for the client and improve their comfort.
D. Administer an opioid narcotic to the client: Opioids can help manage pain and dyspnea in end-of-life care, improving the client's comfort and quality of life by relieving symptoms of distress.
E. Provide deep nasotracheal suctioning for the client: This action is typically not recommended at the end of life as it can cause discomfort and distress without significant benefit. Gentle suctioning, if necessary, should be performed cautiously and with attention to the client's comfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Grandparents: While grandparents can provide useful information, the primary and most accurate data source for a toddler's immediate care and developmental history would typically be the parents, who are the primary caregivers.
B. Admitting provider: The admitting provider offers valuable medical information, but the best source of data regarding the child’s current condition and history would come from those who are closest to the child and involved in their daily care.
C. Parents: Parents are the most reliable source for accurate and up-to-date information about their child’s health, developmental history, and current condition. They are directly involved in the child's daily life and care.
D. Medical record: While the medical record contains important historical data, the most current and relevant information about the toddler’s condition and immediate needs should be obtained from the parents.
Correct Answer is C
Explanation
A. Bronchial airway constriction: During the fight-or-flight response, bronchial airways typically dilate to increase airflow to the lungs, not constrict.
B. Hypoglycemia: The fight-or-flight response typically increases blood glucose levels to provide quick energy, leading to hyperglycemia rather than hypoglycemia.
C. Dilated pupils: Pupils dilate during the fight-or-flight response to enhance vision and perception of potential threats. This is a correct manifestation of the stress response.
D. Decreased blood pressure: The fight-or-flight response usually causes an increase in blood pressure due to the release of adrenaline and other stress hormones that prepare the body for immediate action.
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