A client recovering from pneumonia who has a history of severe chronic obstructive pulmonary disease (COPD and peripheral vascular disease (PVD is being discharged from a skilled nursing facility. Which action is most important for the nurse to implement?

Reinforce the need for adequate hydration.

Provide typed instructions for healthy diet selections.

Explain a daily regimen.

Demonstrate specific strengthening exercises.

Answer and Explanation

The Correct Answer is A

A. Reinforce the need for adequate hydration: Adequate hydration is essential for liquefying secretions in the lungs, especially in clients with COPD who may have increased mucus production. Proper hydration also supports cardiovascular function, particularly in clients with peripheral vascular disease.

B. Provide typed instructions for healthy diet selections: While diet is important for overall health, hydration is the priority in this scenario due to the client's respiratory and vascular conditions.

C. Explain a daily regimen: While educating the client about a daily regimen is important, ensuring adequate hydration takes precedence in this situation.

D. Demonstrate specific strengthening exercises: While exercise is beneficial for clients with COPD and PVD, ensuring proper hydration is more critical for respiratory and cardiovascular function in this scenario.

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Correct Answer is A

Explanation

A. Determining the patient's need for pain medication is a priority to ensure the patient's comfort during the end-of-life care process. Pain management is a critical aspect of palliative care and should be addressed promptly.
B. Updating the nurse manager on the patient's status is important but is not the immediate priority. The nurse manager's awareness does not directly impact the patient's comfort or care at the moment of impending death.
C. Conveying the patient's status to the chaplain may be part of the holistic care approach and can provide spiritual support to the patient and family, but it is not the first priority in terms of the patient's immediate physical needs.
D. Documenting the impending signs of death is essential for legal and medical records; however, it is secondary to addressing the patient's immediate needs, such as pain relief.

A. When the client has ankle edema. B. If the client has an elevated blood pressure. C. During admission to labor and delivery. D. Within the first trimester of pregnancy.

Correct Answer is B

Explanation

A. Assessing DTRs when the client has ankle edema is important, but it is not the most critical time. Ankle edema can be a common occurrence in pregnancy due to increased fluid volume and changes in blood flow.

B. Elevated blood pressure in a pregnant client can be a sign of preeclampsia, a serious condition that can lead to complications for both the mother and the baby. Assessing DTRs can help in
detecting hyperreflexia, which is a sign of preeclampsia. Therefore, it is most important to assess DTRs when there is an elevated blood pressure.

C. While assessing DTRs during admission to labor and delivery is a standard procedure to monitor the client's neurological status, it is not as critical as assessing them when there is an elevated blood pressure.

D. Assessing DTRs within the first trimester of pregnancy is not typically a priority unless there are specific clinical indications or concerns. Elevated blood pressure is a more immediate
concern that requires prompt assessment of DTRs

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A client recovering from pneumonia who has a history of severe chronic obstructive pulmonary disease (COPD and peripheral vascular disease (PVD is being discharged from a skilled nursing facility. Which action is most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A dietitian with a prescription for no not resuscitate (DNR) begins to manifest signs of impending death. After notifying the family of the patient's status, what priority action should the nurse implement?

Correct Answer is A

Explanation

When is it most important for the nurse to assess a pregnant client's deep tendon reflexes (DTRs)?

Correct Answer is B

Explanation

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