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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
A. Remove the dentures from the body: Dentures should typically be left in place unless otherwise directed, as removing them can alter the appearance of the deceased and may be distressing for the family.
B. Dim the lights in the room: Dimming the lights can create a more respectful and soothing environment for the family during their time of mourning.
C. Remove all equipment from the bedside: Removing equipment ensures a clear and respectful presentation of the body, allowing the family to view their loved one without distractions.
D. Apply fresh linens and place a clean gown on the body: This action helps present the body in a respectful manner, making it more presentable for the family.
E. Make sure the body is lying completely flat: The body should be positioned appropriately based on the clinical setting and family preferences, but the focus should be on creating a respectful and dignified presentation rather than strictly ensuring the body is completely flat.
Correct Answer is A
Explanation
A. Current Medical condition: The situation component of ISBARR focuses on the patient's current medical condition and why they are in the facility. It provides a snapshot of the client's immediate situation.
B. List of medications: While important, the list of medications is more relevant to the background or assessment components of the report.
C. Vital signs: Vital signs are part of the assessment, providing data on the client’s current health status.
D. Treatment: Treatment information falls under the recommendation or background sections of the report, detailing the plans or historical context rather than the immediate situation.
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