A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement)

The client's need for pain medication should be determined.

The nurse manager should be updated on the client's status

The client's status should be conveyed to the chaplain.

The impending signs of death should be documented

Answer and Explanation

The Correct Answer is A

A. Determining the client's need for pain medication is a priority to ensure comfort and manage symptoms as the client approaches end of life.
B. Updating the nurse manager on the client's status is important, but it is not the priority action in terms of direct client care.
C. Conveying the client's status to the chaplain may be part of holistic care, but the immediate physical needs of the client take precedence.
D. Documenting the impending signs of death is essential for medical records, but addressing the client's comfort needs is the priority.

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Correct Answer is C

Explanation

A. A sluggish blood return: While a sluggish blood return may indicate potential issues with the IV line, it does not require immediate intervention unless accompanied by other signs of
complications.
B. Cool sensation above the site: Cool sensation above the site may indicate impaired circulation, but it is not as concerning as other findings requiring immediate intervention.
C. Iced streak tracking the vein: Correct! An iced streak tracking the vein suggests infiltration of IV fluids into the surrounding tissue, which can cause tissue damage and compromise the
effectiveness of the IV therapy. Immediate intervention is needed to prevent further complications.
D. Circumferential skin irritation: Circumferential skin irritation may indicate an allergic reaction or contact dermatitis, which requires attention but is not as urgent as an infiltration.

A. Center attention on positive upbeat music. B. Find outlets for more social interaction. C. Practice using muscle relaxation techniques. D. Think about reasons the episodes occur.

Correct Answer is C

Explanation

A. Center attention on positive upbeat music . While positive music can be helpful for some individuals in managing anxiety, it may not be effective for everyone, especially those experiencing moderate anxiety.

B. Find outlets for more social interaction: Increasing social interaction may be beneficial for managing anxiety for some individuals, but it may not address the underlying issues contributing to recurrent moderate anxiety.

C. Practice using muscle relaxation techniques: Muscle relaxation techniques, such as progressive muscle relaxation or deep breathing exercises, can help reduce physical tension and promote relaxation, which can be effective in managing anxiety symptoms.

D. Think about reasons the episodes occur: While understanding triggers for anxiety episodes is important, simply thinking about the reasons may not provide immediate relief or effective coping strategies for managing anxiety symptoms.

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A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing a routine assessment of an IV site for a client receiving both IV fluids and medications through the line. The client reports tenderness when the nurse touches the arm above the site. Which finding should the nurse expect which will require immediate intervention?

Correct Answer is C

Explanation

The nurse is providing education to a client who experiences recurrent levels of moderate anxiety to situations and perceived stress. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching?

Correct Answer is C

Explanation

A client is being urgently transported to radiology for a Computerized Tomography (CT scan) after a sudden decrease in level of consciousness. The client is orally intubated and has a left lateral chest tube to 20 cm suction. Which action is most important for the take?

Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter?

A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement)

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