A client with end-stage lung disease is dependent on a mechanical ventilator to sustain life. While the client's spouse is at the bedside, the client pleads in handwritten notes to have the endotracheal tube removed. The spouse tearfully agrees with the request. Which is the priority nursing intervention?

Offer to contact the family's spiritual counselor to meet with the client and spouse.

Discuss comfort measures with the client and family that will be available during withdrawal.

Inform the healthcare provider of the client's desire to have life support withdrawn.

Explain the actions that the healthcare team will follow for the removal of life support.

Answer and Explanation

The Correct Answer is C

Choice A reason: Offering to contact the family's spiritual counselor can provide emotional and spiritual support, but it is not the immediate priority in a situation where the client has expressed a desire to have life support withdrawn.

Choice B reason: Discussing comfort measures is important for the client and family to understand what to expect during the withdrawal process. However, this step comes after the healthcare provider has been informed and a plan of care is being developed.

Choice C reason: Informing the healthcare provider is the priority nursing intervention. The nurse acts as an advocate for the client's wishes and ensures that the appropriate steps are taken to respect the client's autonomy and decisions regarding their care.

Choice D reason: Explaining the actions that the healthcare team will follow is an essential part of the process, but it is not the first step. The healthcare provider must first be informed so that the proper orders and arrangements can be made.

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Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason: Before initiating tube feeding, it is crucial to ensure that the gastrointestinal system is functioning. The presence of bowel sounds indicates peristalsis, which is necessary for the digestion and absorption of the feeding.

Choice B reason: While measuring the client's total body weight is important for overall assessment and monitoring of nutritional status, it is not the most critical assessment before starting tube feeding.

Choice C reason: Evaluating the client's ability to swallow is not relevant in this scenario since the client will be receiving nutrition through a feeding tube due to malnutrition and dehydration.

Choice D reason: Observing for signs of fluid volume deficit is important, but the immediate concern before starting tube feeding is to confirm gastrointestinal activity through the presence of bowel sounds.

A. Give the patient 8 ounces (240 mL) of water to drink. B. Notify the healthcare provider. C. Check the drainage tubing for a kink. D. Review the intake and output record.

Correct Answer is C

Explanation

Choice A reason: Giving water may be necessary, but it is not the first intervention if there is a concern about urinary output.

Choice B reason: Notifying the healthcare provider is important but should occur after initial assessments and interventions.

Choice C reason: Checking for a kink in the drainage tubing is a quick and simple intervention that may resolve the issue of low output.

Choice D reason: Reviewing the intake and output record is important for understanding the patient's fluid status but is not the first action to take in this situation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is admitted for malnutrition and severe dehydration receives a prescription for liquid feedings through a feeding tube. After the feeding tube is inserted and placement confirmed, which assessment is most important for the nurse to complete before starting the feeding?

Correct Answer is A

Explanation

The nurse receives a report that a patient with an indwelling urinary catheter has an output of 150 mL for the previous 8-hour shift. Which intervention should the nurse implement first?

Correct Answer is C

Explanation

When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. Which action should the nurse take next?

The nurse is preparing an in-service on the Health Insurance Portability and Accountability Act (HIPAA) violations. Which example should the nurse use to demonstrate a HIPAA violation?

While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. Which action should the nurse take in response to this finding?

A client is admitted with pneumonia and has a recent history of methicillin-resistant Staphylococcus aureus (MRSA). The client is placed in isolation. When caring for the client, which item should the nurse place in a designated biohazard bag before it is removed from the room?

The home health nurse is reviewing the personal care needs of an older adult client who lives alone. What client assessment finding(s) indicate(s) the need to assign an unlicensed assistive personnel (UAP) to provide routine foot care and has the client's toenails? Select all that apply.

A client is in the terminal stage of lung cancer. Outside the room, the client's spouse expresses to the nurse feelings of helplessness and a lack of hope for the future. How should the nurse respond?

While assisting a client with oral care, the nurse assesses the client's mouth. It is most important for the nurse to take action in response to which finding?

A client with emphysema tells the nurse that sitting upright in bed makes breathing easier. Which instruction is most important for the nurse to provide the assigned unlicensed assistive personnel (UAP)?