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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Correct Answer is D

Explanation

A. While determining if medications can be given in generic form can be a cost-effective measure and might be beneficial for the client, it is not the most urgent action to take during the admission process. The primary focus should be on ensuring that the medications are correct, safe, and appropriate for the client’s current condition and needs.
B. Client education about the desired effects of medications is important for ensuring the client understands their treatment and can identify any side effects or issues. However, this is typically done after ensuring that the medication list is accurate and reconciled. Teaching should be part of a comprehensive plan once the medication list and dosages are confirmed.
C. Reconciliation of prescribed medication dosages with recommended dosage ranges is important for ensuring the client receives appropriate and safe dosages. However, this action is part of a broader process of medication reconciliation, which involves verifying and comparing the current list of medications against previous records and established guidelines.
D. Comparing admission prescriptions with the list of medications previously taken by the client is a crucial first step in the medication reconciliation process. This action ensures that there is no duplication, omission, or incorrect change in the medication regimen. It helps prevent potential medication errors and ensures continuity of care.

A. Add the second portion of the feeding before the syringe is completely empty. B. Use 25 mL of water between the two portions of the feeding to flush the GT. C. Raise the syringe barrel higher to increase the flow rate of the bolus feeding. D. Flush the tube with 50 mL of water between the two portions of the feeding.

Correct Answer is D

Explanation

A. This instruction is not recommended because adding the second portion of the feeding before the syringe is empty can lead to inconsistent feeding rates and potential complications, such as overloading the stomach with too much formula at once.
B. Flushing the GT with water between portions of feeding is a good practice to prevent clogging and to ensure that all formula is delivered. However, 25 mL of water is generally not enough; standard practice typically involves using 30 to 60 mL of water for effective flushing. This option is close but not as specific as the recommended volume.
C. Raising the syringe barrel can increase the flow rate of the feeding, but this approach should be used with caution. Rapid flow can cause gastrointestinal discomfort or cramping. The primary focus should be on ensuring proper flushing and administration rather than manipulating the flow rate in this way.
D. This option is the best practice because flushing the GT with 50 mL of water between portions of the feeding helps to clear any remaining formula from the tube and prevents clogging. Proper flushing also helps ensure that the entire dose of formula is delivered and maintains tube patency.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older client is being admitted to a rehabilitation unit from a medical-surgical unit following a left hip replacement. When reviewing the client's prescribed medications, which intervention should the nurse implement first?

Correct Answer is D

Explanation

Correct Answer is D

Explanation

The nurse is teaching another nurse about the administration of medication using the Z track technique. Which is the primary reason for using a Z track technique to administer a medication?

The charge nurse is observing a new nurse administering care during new hire orientation at the hospital. Which activity by the new nurse indicates correct body movement and posture to reduce the risk for injury?

An older adult client is admitted to a long term care facility. Upon admission, the client is oriented but fatigued, is incontinent of urine, and has a stage II pressure ulcer on the left heel. Which additional finding requires further assessment?

An older adult client grimaces and demonstrates guarding behavior, but denies experiencing pain when asked by the nurse to rate the pain on a numeric scale. Which action should the nurse take next?

While cleansing a client's surgical incision, the nurse observes the incision as seen in the picture. How should the nurse document the appearance of the incision?

Which breakfast selection indicates that the client understands the nurse's instructions about the dietary management of osteoporosis?

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?