A client who is terminally ill has an advance directive that stipulates no resuscitative measures are to be taken. The client's death is imminent and the family is in the client's room. The client is currently exhibiting Cheyne-Stokes respirations and has a blood pressure of 60/30 mm Hg. Which is the priority nursing action?

Allow privacy for the family and client to express their feelings to one another.

Apply an automatic blood pressure cuff and take readings every 15 minutes.

Teach the client's family how to use an oral suction device to clear the airway.

Elevate the head of the client's bed and apply oxygen using a face mask.

Answer and Explanation

The Correct Answer is A

A.   Allowing privacy for the family and client is a compassionate and appropriate action, especially as the client's death is imminent. This respects the client's wishes and provides a supportive environment for the family to process their emotions and say their goodbyes.
B.   Continuously measuring blood pressure in this scenario is less appropriate because the client is in the final stages of life and their focus should be on comfort rather than monitoring vital signs. Frequent blood pressure measurements may be distressing for the family and do not align with the goals of end- of-life care, which prioritize comfort and dignity.
C.   Teaching the family to use an oral suction device is not appropriate at this stage because the client is actively dying, and such interventions are not typically useful or necessary in end-of-life care. The focus should be on providing comfort rather than invasive procedures or teaching new skills to family members.
D.   Applying oxygen and elevating the head of the bed can be appropriate interventions for clients experiencing respiratory distress; however, this may conflict with the advance directive if the directive explicitly states no resuscitative measures

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. CRP is an acute-phase protein produced by the liver in response to inflammation. Elevated CRP levels indicate systemic inflammation or infection. Measuring the CRP level can help confirm the presence of an inflammatory process, such as infection, and monitor the severity of inflammation. However, while useful, CRP alone might not provide the complete picture needed for specific wound management.
B. Culturing the wound for sensitive organisms is crucial when an infection is suspected. This test will identify the specific bacteria or other pathogens causing the infection and determine their sensitivity to various antibiotics. This information is essential for choosing the appropriate treatment to address the infection effectively.
C. Serum albumin levels provide information about the client’s nutritional status and can reflect protein malnutrition. Low serum albumin levels can indicate poor wound healing due to inadequate protein levels, which affects tissue repair. While serum albumin is important for understanding overall nutritional status, it does not directly diagnose or confirm infection.
D. Blood glucose levels are important to monitor, especially in diabetic patients, as high blood glucose can impair wound healing and increase the risk of infections. However, blood glucose levels are more related to the client's ability to heal rather than directly identifying or managing an infection.

A. The consistency of the prescribed diet. B. Review of current medications. C. Client's ability to chew and swallow. D. The client's respiratory rate and lung sounds.

Correct Answer is C

Explanation

A. Knowing the consistency of the prescribed diet (e.g., pureed, mechanical soft, or regular) is important for planning the feeding process and ensuring that the diet meets the client's needs and restrictions. However, this information is secondary to assessing the client’s ability to safely chew and swallow.
B. While reviewing current medications is important for understanding potential drug interactions, side effects, or dietary restrictions, it is not the most immediate concern before feeding. Medications can influence appetite and digestion, but the priority is ensuring the client can safely handle the food.
C. This is the most critical information to obtain before feeding a debilitated client. Assessing the client's ability to chew and swallow helps prevent complications such as aspiration, choking, or aspiration pneumonia. The nurse should ensure that the client can safely manage the food given to them and that their swallowing mechanisms are functioning adequately.
D. While monitoring the respiratory rate and lung sounds is important for overall health assessment, it is not the immediate priority before starting a feeding session. However, it is important to monitor for signs of aspiration during and after feeding, as compromised swallowing can lead to aspiration pneumonia.

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Naxlex Comprehensive Predictor Exams

While changing the dressing of a client who is immobile, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

Correct Answer is B

Explanation

The nurse is preparing to feed a newly admitted older adult client who is debilitated, but is able to respond to most commands. Before starting to feed the client, which information is most important for the nurse to obtain?

Correct Answer is C

Explanation

A client with a colostomy tells the nurse about making small pin holes in the drainage bag to help relieve the gas that collects. Which action should the nurse implement?

The nurse implements a change in the approach to client care after gathering evidence in support of the new approach. Which action should the nurse take next?

When entering a client's room, the nurse observes the client holding up an arm and coughing non-productively into the upper sleeve. Which action should the nurse take?

Which assessment is most important for the nurse to perform prior to the application of a heating pad?

In planning the turning schedule for a bedfast client, it is most important for the nurse to consider which assessment finding?

The nurse is assessing an older female client who was admitted to a long-term facility two days ago. The resident refuses to go to the dining room for meals and calls for help with all activities of daily living. Which nursing problem is best to include in this client's plan of care?

The nurse assesses an adult client with a partial rebreather mask and notes that the oxygen reservoir bag does not deflate completely during inspiration and the client's respiratory rate is 14 breaths/minute. Which action should the nurse implement?