A nurse is caring for a client who is terminally ill and has a do-not-resuscitate order on his medical record. The client asks, "What should I do if I have difficulty breathing?" Which of the following responses should the nurse make?
"Call me so that I can help you change your position."
"Try to close your eyes and get some sleep."
"It is common for breathing to become more difficult as time goes on."
"Therapy choices are limited for clients who do not want resuscitation."
The Correct Answer is A
Choice A Reason:
"Call me so that I can help you change your position." This response offers practical assistance and comfort to the client. Repositioning can sometimes alleviate discomfort associated with breathing difficulties, and the nurse can offer guidance or physical help to adjust the client's position for improved comfort.
Choice B Reason:
"Try to close your eyes and get some sleep." This response doesn't directly address the client's immediate concern about difficulty breathing and may not offer practical help.
Choice C Reason:
"It is common for breathing to become more difficult as time goes on." While this statement acknowledges the situation, it might not provide the client with actionable guidance or support on how to manage the difficulty in breathing.
Choice D Reason:
"Therapy choices are limited for clients who do not want resuscitation." This response might be interpreted as dismissive or unrelated to the client's immediate needs, focusing more on the DNR order rather than addressing the current concern about breathing difficulties.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:Using direct quotes from the client in the incident report is appropriate because it provides an accurate and objective account of the client's perspective. This is an important part of documenting the incident.
Choice B Reason:Incident reports are meant to be internal documents used for quality improvement and risk management. Noting in the medical record that an incident report was completed is not appropriate, as it could imply liability or affect the legal status of the report.
Choice C Reason:The nurse should not draw conclusions about the cause of the incident in the incident report. The report should contain only objective facts, not assumptions or interpretations.
Choice D Reason:
The nurse should not draw conclusions about the cause of the incident in the incident report. The report should contain only objective facts, not assumptions or interpretations.
Correct Answer is B
Explanation
Choice A Reason:
Inflating the catheter's balloon is done after proper placement to secure the catheter in the bladder. It should not be done when there is resistance and no urine flow.
Choice B Reason:
Twisting the catheter gently is correct. Resistance during catheter insertion may indicate the catheter is encountering an obstruction or is misaligned. Gently twisting the catheter can help navigate around obstructions or correct misalignment without causing trauma to the urethra.
Choice C Reason:
Applying lidocaine gel to the urethra is typically used for lubrication and to numb the urethra during catheter insertion, but it may not address the issue of resistance or lack of urine flow.
Choice D Reason:
Lowering the penis to a 45° angle is not a standard action in response to resistance during catheter insertion. Twisting the catheter gently is a more appropriate initial step.
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