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 ["B","D","E"]

Explanation

A. A diet low in phosphorus is not typically indicated for cirrhosis of the liver. Cirrhosis primarily affects the body's ability to handle proteins and not phosphorus.
B. Noting signs of swelling and edema is important as these are common complications of cirrhosis due to hypoalbuminemia and portal hypertension.
C. Increasing oral fluid intake is not advised as it can exacerbate fluid retention and ascites, which are complications of cirrhosis.
D. Monitoring abdominal girth is crucial for assessing changes in ascites and potential fluid overload.
E. Reporting serum albumin and globulin levels is essential as these can indicate the severity of liver disease and help guide treatment.

A. Measure abdominal girth. B. Assess perineal area. C. Inspect the insertion site. D. Palpate flank area.

Correct Answer is C

Explanation

A. Measuring abdominal girth is not specific to suprapubic catheter care. While it may be relevant in certain situations, it does not directly assess the condition of the catheter or its insertion site.

B. Assessing the perineal area is important, but the primary focus for a client with a suprapubic catheter should be on the insertion site itself, as this is where complications such as infection or leakage are most likely to occur.

C. Assessing the insertion site is essential to monitor for any signs of infection, inflammation, or other complications related to the catheter. This assessment helps ensure the catheter is functioning correctly and that no adverse effects are developing.

D. Palpating the flank area is generally not a routine assessment for a client with a suprapubic catheter unless there are specific concerns about kidney function or pain in that area.

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Body System	Assessment Finding
Cardiovascular	BP 145/89 mmHg Heart Rate 101 bpm Capillary refill 4 seconds
Neurologic	Awake and alert Anxious and Restless
Respiratory	Oxygen saturation 90% Respiratory rate 28bpm Productive cough

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

A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention(s) should the nurse implement? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

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

Correct Answer is C

Explanation

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