Patient Data

Exhibits

Which intervention should the nurse prioritize for this client?

Administer pain medication as prescribed.

Provide emotional support to the family.

Assist with daily activities.

Monitor vital signs regularly.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Administering pain medication as prescribed is the priority intervention for a client receiving hospice care with significant pain and discomfort. Effective pain management is essential to ensure the client’s comfort and quality of life. Pain relief is a primary goal in hospice care, and regular administration of pain medication helps manage symptoms and improve the client’s overall well-being.

Choice B rationale

Providing emotional support to the family is important in hospice care, as families often need assistance coping with the emotional challenges of caring for a loved one with a terminal illness. However, the priority intervention is to manage the client’s pain and discomfort effectively.

Choice C rationale

Assisting with daily activities is necessary for clients with limited mobility, but it is not the primary intervention. Ensuring the client’s comfort and pain relief takes precedence, as it directly impacts their quality of life.

Choice D rationale

Monitoring vital signs regularly is part of the overall care plan, but it is not the priority intervention. The focus should be on managing the client’s pain and discomfort to provide the best possible quality of life in hospice care.

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Correct Answer is B

Explanation

Choice A rationale

Testing for a gag reflex before performing oral care is a standard practice to ensure the client’s safety and prevent aspiration. This action does not indicate a need for additional training.

Choice B rationale

Placing the client in a supine position is incorrect and indicates a need for additional training. The correct position for performing oral care on an unconscious client is a side-lying position to prevent aspiration and ensure secretions can drain from the mouth.

Choice C rationale

Suctioning secretions from the posterior pharynx is a necessary action to maintain airway patency and prevent aspiration. This action does not indicate a need for additional training.

Choice D rationale

Using an oral airway to keep the teeth apart is a standard practice to facilitate oral care and prevent the client from biting down on the caregiver’s fingers or equipment. This action does not indicate a need for additional training.

A. Report the client’s status to the healthcare provider. B. Ask the UAP to complete postmortem care. C. Begin cardiopulmonary resuscitation (CPR) and call a code. D. Notify the family of the client’s death. E. Notify the family of the client’s death.

Correct Answer is A

Explanation

Choice A rationale

Reporting the client’s status to the healthcare provider is the appropriate action. The healthcare provider needs to be informed of the client’s death to provide further instructions and complete necessary documentation. This action ensures proper communication and adherence to protocols.

Choice B rationale

Asking the UAP to complete postmortem care is necessary, but it should be done after notifying the healthcare provider. The nurse must follow the proper sequence of actions to ensure all protocols are followed.

Choice C rationale

Beginning cardiopulmonary resuscitation (CPR) and calling a code is not appropriate because the client has a signed do not resuscitate (DNR) form. Performing CPR would go against the client’s wishes and legal documentation.

Choice D rationale
Notifying the family of the client’s death is important, but it should be done after reporting the client’s status to the healthcare provider. The healthcare provider may have specific instructions for communicating with the family and completing necessary documentation.

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Patient Data Exhibits Which intervention should the nurse prioritize for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes a practical nurse (PN) performing oral care on an unconscious client. Which action by the PN indicates to the nurse the need for additional training?

Correct Answer is B

Explanation

An older adult client with heart failure has a signed do not resuscitate (DNR) form in the medical record. The unlicensed assistive personnel (UAP) reports that the client is not breathing, and the nurse confirms the UAP’s findings. Which action should the nurse take next?

Correct Answer is A

Explanation

The nurse is assessing a client who is having pain in the right upper abdominal area. To assess the quality of the client’s abdominal pain, which approach should the nurse use?

Patient Data Exhibits Which intervention should the nurse prioritize for this client?

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A nurse administers an opioid analgesic to a postoperative client who also has severe obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client alone?

A client is admitted to the rehabilitation unit following a cerebrovascular accident (CVA), which resulted in paralysis of the right arm. When the nurse enters the room, the client is struggling to put on a shirt and curses at the nurse. Which response is best for the nurse to provide?

The nurse observes the unlicensed assistive personnel (UAP) securing a client’s wrist restraints to the bedside rails. Which action is most important for the nurse to implement?

A confused older adult client is having trouble sleeping at night and is sometimes found wandering in the hallway. Which nursing intervention should the nurse implement first?

A client who had emergency gallbladder surgery yesterday is getting ready for discharge. The client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client’s understanding of self-care at home?

Patient Data

Exhibits

Which intervention should the nurse prioritize for this client?