The nurse is caring for a client with terminal lung cancer who is dying. Which assessment finding is the priority?
Restlessness and moaning
Cheyne-Stokes respirations
Urinary and fecal incontinence
Irregular heart rhythm
The Correct Answer is A
A. Restlessness and moaning are clinical indicators of terminal agitation or physical pain, both of which require immediate pharmacological or comfort intervention. Addressing suffering is the primary ethical and clinical goal of end-of-life care to ensure a peaceful transition. The nurse must prioritize these signs of distress over expected physiological changes that occur naturally during the active dying process in terminal cancer.
B. Cheyne-Stokes respirations are characterized by a rhythmic pattern of waxing and waning breathing depth followed by periods of apnea. This is a common and expected physiological sign of impending death as the brainstem becomes increasingly hypoxic and loses sensitivity to carbon dioxide. While significant to the family, it is not a sign of distress and does not require active medical intervention in hospice.
C. Loss of sphincter control leading to urinary and fecal incontinence is a natural result of generalized muscle relaxation and the shutting down of the nervous system during death. While this requires diligent skin care and hygiene to maintain the client's dignity and prevent breakdown, it is not an acute priority. The nurse should manage this with absorbent pads to keep the client dry and comfortable.
D. An irregular heart rhythm often occurs in the final stages of life as the cardiac conduction system fails and the heart becomes increasingly irritable. This expected hemodynamic decline is a part of the multisystem organ failure associated with terminal lung cancer and is not typically treated with antiarrhythmics in palliative care. The focus remains on comfort rather than the restoration of a normal sinus rhythm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A.A fasting glucose level of 78 mg/dL is within the normal glycemic reference range of 70 to 110 mg/dL for an adult client. In a client with diabetes, this value indicates effective metabolic control and does not signal an acute hypoglycemic or hyperglycemic crisis. The nurse should continue to monitor the client and follow the established medication and dietary plan without needing an urgent provider notification.
B.A hemoglobin level of 11.5 g/dL is slightly below the standard adult reference range but is frequently observed and tolerated in the immediate postoperative period. Minor blood loss during surgery or hemodilution from intravenous fluid administration can cause this expected drop. Unless the client exhibits symptomatic anemia, such as tachycardia or hypotension, this value does not represent a clinical emergency requiring immediate reporting.
C.An international normalized ratio (INR) of 5.2 is significantly above the typical therapeutic range of 2.0 to 3.0 for a client on warfarin therapy. This supratherapeutic level places the client at an extreme risk for spontaneous, life-threatening hemorrhage and requires immediate provider notification for dose adjustment or vitamin K administration. The nurse must also assess the client for any occult or overt signs of bleeding.
D.A blood urea nitrogen (BUN) of 19 mg/dL is within the normal clinical reference range of 10 to 20 mg/dL for a healthy adult. This result indicates that the client’s kidneys are effectively filtering nitrogenous waste and that the current intravenous fluid rate is maintaining adequate renal perfusion. There is no evidence of dehydration or renal insufficiency that would necessitate a change in the medical management or a report.
Correct Answer is ["250"]
Explanation
Step 1 is to identify the ordered dose per hour and the available concentration in the IV bag
Ordered Dose: 20 mEq/hr
Available Amount: 40 mEq
Available Volume: 500 mL
Step 2 is to calculate the concentration of the solution in mEq per mL
mEq per mL = Total mEq ÷ Total mL
40 ÷ 500 = 0.08 mEq/mL
Step 3 is to calculate the infusion rate in mL per hour
mL/hr = Ordered Dose ÷ Concentration
20 ÷ 0.08 = 250
Step 4 is to round to the nearest whole number
250 = 250
Answer: 250
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.