An older woman who was recently diagnosed with end stage metastatic breast cancer is admitted because she is experiencing shortness of breath and confusion. The client refuses to eat and continuously asks to go home. Arterial blood gas results indicate hypoxia. Which intervention is most important for the nurse to implement?
Clarify end of life desires.
Offer sips of favorite beverages.
Initiate comfort measures.
Prepare for emergent oral intubation.
The Correct Answer is C
A. Clarify end of life desires: While understanding a client’s goals is vital, this may not address her immediate needs. The client is already showing signs of distress and hypoxia, so initiating comfort measures promptly is more urgent than discussing future preferences.
B. Offer sips of favorite beverages: Offering fluids may help with oral comfort but does not address the client’s respiratory distress or overall suffering. It is a low-priority intervention in the setting of acute hypoxia and confusion related to terminal illness.
C. Initiate comfort measures: Comfort measures are the priority for a terminally ill client with hypoxia and confusion who is refusing food and expressing a wish to go home. This aligns care with the client's likely stage in the dying process and ensures symptom relief over aggressive interventions.
D. Prepare for emergent oral intubation: Intubation is invasive and likely inconsistent with palliative goals in end-stage cancer. Without clear patient consent or indication that life-prolonging measures are desired, focusing on comfort is more appropriate and ethical.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Maintain strict intake and output: Maintaining strict intake and output is essential in septic shock to monitor renal function and ensure adequate perfusion. Decreased urine output can indicate worsening shock or kidney failure, which requires prompt intervention.
B. Assess warmth of extremities: Early signs of septic shock often include cool or mottled extremities due to poor circulation, which should be addressed more through perfusion monitoring than by focusing solely on warmth.
C. Keep head of bed raised 45 degrees: Elevating the head of the bed may be helpful in certain situations, but it is not the most critical intervention for septic shock. The priority is to ensure proper hemodynamic monitoring, fluid resuscitation, and organ perfusion.
D. Monitor blood glucose level: While monitoring blood glucose is important in critically ill clients, it is not the immediate priority in septic shock. Sepsis often causes hyperglycemia, but managing fluid resuscitation and organ perfusion is the most urgent intervention.
Correct Answer is B
Explanation
A. Clitoris: This is a highly sensitive erectile tissue and not connected to the urinary system.
B. Urethra: This is the correct site for catheter insertion, as it leads directly into the urinary bladder.
C. Labia: These are external folds of skin that surround the urethral and vaginal openings, not the site for catheter insertion.
D. Vagina: Inserting a catheter here would result in incorrect placement. The vagina is posterior to the urethra.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.