A client is receiving palliative care, and death is anticipated within the next 24 hours. The practical nurse (PN) observes that the client's legs have a mottled appearance. What should the PN apply to the client's legs?

Heating pad

Body lotion

Soft blanket

Moist clothes

Answer and Explanation

The Correct Answer is C

The correct answer is Choice C. Soft blanket.

Choice A rationale:

A heating pad should not be applied to the client's legs with a mottled appearance. A mottled appearance indicates poor circulation, and applying heat could potentially worsen the situation by dilating blood vessels and further reducing blood flow to the extremities.

Choice B rationale:

The body lotion is not appropriate in this situation. While it may help moisturize the skin, it will not address the underlying circulation issues causing the mottled appearance. Moreover, applying lotions to areas with compromised circulation can be harmful.

Choice C rationale:

The correct choice. A soft blanket can be applied to the client's legs with a mottled appearance to provide warmth and comfort. It is essential to keep the client comfortable during palliative care, and a soft blanket can help maintain a suitable temperature without causing harm.

Choice D rationale:

Moist clothes are not indicated in this situation. They may potentially worsen the mottled appearance by adding moisture to the skin, and it won't address the circulation issues causing the discoloration.

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Correct Answer is B

Explanation

Choice A rationale:

While measuring urinary output is an important nursing intervention, it may not be the most critical action for a client with left-sided heart failure. Left-sided heart failure primarily affectspulmonary circulation, and assessing lung sounds is a priority in this situation.

Choice C rationale:

Checking mental acuity is a valid nursing intervention, but it may not be the most crucial action for a client with left-sided heart failure. The priority in this case is to monitor respiratory status and identify any signs of respiratory distress.

Choice D rationale:

Inspecting for sacral edema is also a relevant nursing intervention, as it can indicate fluid retention in heart failure patients. However, auscultating the lung fields takes precedence in this scenario to assess for signs of pulmonary congestion, which is a common complication of left-sided heart failure.

A. Oﬀer nipple feedings of 10% dextrose. B. Begin frequent feedings of breast milk or formula. C. Repeat the heel stick for glucose in one hour. D. Assess for signs of hypocalcemia.

Correct Answer is B

Explanation

The infant has hypoglycemia, which is a low blood glucose level that can cause jitteriness, lethargy, seizures, or coma. Hypoglycemia is common in infants of mothers with gestational diabetes, as they produce excess insulin in response to high maternal glucose levels. The PN should begin frequent feedings of breast milk or formula, as this can provide a source of glucose and stimulate the infant's own glucose production.

The other options are not correct because:

A. Oﬀering nipple feedings of 10% dextrose may be indicated in some cases of severe hypoglycemia, but it is not the first intervention. The PN should try oral feedings of breast milk or formula first, as they are more natural and less invasive.

C. Repeating the heel stick for glucose in one hour may be necessary to monitor the infant's glucose level, but it is not the first intervention. The PN should treat the hypoglycemia first, as it can have serious consequences if left untreated.

D. Assessing for signs of hypocalcemia may be important, as hypocalcemia is another possible complication in infants of mothers with gestational diabetes, but it is not the first intervention. The PN should address the hypoglycemia first, as it is more urgent and more likely to cause jitteriness.

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A client is receiving palliative care, and death is anticipated within the next 24 hours. The practical nurse (PN) observes that the client's legs have a mottled appearance. What should the PN apply to the client's legs?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is assessing an older client with left-sided heart failure (HF). What intervention is most important for the PN to implement?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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