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. Yogurt or buttermilk: Cefdinir can disrupt the normal balance of bacteria in the gut. Yogurt or buttermilk, which contain probiotics, can help restore beneficial bacteria and reduce the risk of gastrointestinal complications such as antibiotic-associated diarrhea.
B. Avocados and cheese: While these are healthy foods, they do not specifically support gut health in the same way that probiotics do. Additionally, cheese may be high in fat and could potentially exacerbate gastrointestinal discomfort.
C. Fresh fruits: Fresh fruits provide important vitamins and fiber, but they do not specifically target the restoration of normal gut flora. Some fruits may also be difficult for a client with a postoperative wound infection to tolerate, especially if they are experiencing digestive issues.
D. Green leafy vegetables: While green leafy vegetables are nutritious, they do not have a direct role in supporting gut flora during antibiotic therapy. They are rich in vitamins and minerals, but the focus should be on probiotics like yogurt or buttermilk.
Correct Answer is D
Explanation
A. Abdominal cramping: Abdominal cramping can be a common symptom of gastritis and may not necessarily require immediate reporting unless it is severe or accompanied by other concerning symptoms.
B. Low grade fever: A low-grade fever can occur with gastritis as part of the inflammatory response, but it is not an immediate concern unless it persists or worsens. It is generally not as urgent as other symptoms.
C. Bruising of the skin: Bruising is not a typical symptom of gastritis. It may be indicative of a bleeding disorder or other underlying issues unrelated to the gastrointestinal system. However, it is not directly associated with gastritis.
D. Bloody emesis: Bloody emesis (vomiting blood) is a critical sign that indicates possible gastrointestinal bleeding, which can occur with severe gastritis. This is an emergency situation and should be reported immediately as it requires urgent medical attention.
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