A nurse is reinforcing teaching about end-of-life care with the partner of a client.Which of the following statements should the nurse make?
"Encourage your partner to eat three large meals each day.”.
"Opioids will be restricted if your partner develops respiratory distress.”.
"We will use an electric blanket to keep your partner warm.”.
"Assume your partner can hear you, even if they do not respond.”. .
The Correct Answer is D
Choice A rationale
Encouraging a partner to eat three large meals each day may not be appropriate in end-of-life care. Clients often have reduced appetite, and small, frequent meals are usually recommended to avoid overwhelming them.
Choice B rationale
Opioids are commonly used in end-of-life care to manage pain and distress. Even if respiratory distress occurs, opioids are not typically restricted, but rather adjusted to balance pain relief and respiratory function.
Choice C rationale
Using an electric blanket can pose safety risks, including burns or electrical hazards, especially if the client is unable to communicate discomfort. Instead, alternative methods such as warm blankets are safer.
Choice D rationale
Assuming the partner can hear even if they do not respond is important. Hearing is believed to be one of the last senses to fade, and speaking to the client can provide comfort and connection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale: The client’s respiratory rate of 10/min is below the normal range (12-20 breaths per minute). This suggests respiratory depression, which can be caused by opioid medications like morphine.
Choice B rationale: The client’s pulse oximetry reading of 88% on room air is lower than the normal range (95%-100%). This indicates hypoxemia, which may be due to respiratory depression from the morphine.
Choice C rationale: Although the blood pressure of 99/46 mm Hg is low, it might be acceptable for this client postoperatively. However, it does not require immediate intervention compared to the other choices.
Choice D rationale: The administration of morphine 10 mg subcutaneously needs further action because the client is showing signs of opioid overdose (e.g., respiratory depression, hypoxemia). This necessitates reassessment and potential adjustment of the medication dosage or frequency.
Correct Answer is C
Explanation
Choice A rationale
Injecting air into the ampule prior to drawing the medication into a syringe is incorrect because ampules are sealed glass containers, and injecting air could cause the liquid to spill out due to pressure changes.
Choice B rationale
Adding 0.5 mL of diluent to the medication is not appropriate for most medications in ampules unless specifically instructed by the medication guidelines. Ampules typically contain ready-to-use medication.
Choice C rationale
Using a filter needle to aspirate the medication is the correct action. A filter needle is used to prevent any glass particles from being drawn into the syringe, ensuring the medication is safe for administration.
Choice D rationale
Cleansing the tip of the ampule with an alcohol swab after opening is unnecessary because the ampule's contents are sterile and the risk of contamination is minimized if the ampule is handled correctly.
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