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Inform the healthcare provider of the client's desire to have life support withdrawn.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but it is not the immediate priority in a situation where the client has expressed a desire to have life support withdrawn.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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Correct Answer is C

Explanation

Choice A reason: Completing an admission assessment is typically the responsibility of a registered nurse (RN) due to the comprehensive nature of the assessment.

Choice B reason: Accessing a central venous line is usually within the scope of practice of an RN, not a PN, due to the complexity and potential complications associated with central lines.

Choice C reason: Reinforcing discharge teaching is an appropriate task for a PN, as it involves reviewing and ensuring the client understands the instructions already provided by the RN or healthcare provider.

Choice D reason: Initiating blood product infusions is generally the responsibility of an RN because of the critical nature of the task and the potential for adverse reactions.

A. Discontinue the use of the nasal cannula. B. Apply lubricant to the cannula tubing. C. Place padding around the cannula tubing. D. Decrease the flow rate to 1 L/minute.

Correct Answer is C

Explanation

The correct answer is choice c. Place padding around the cannula tubing.

Choice A rationale:

Discontinuing the use of the nasal cannula is not appropriate because the client still needs supplemental oxygen to maintain adequate oxygen saturation levels.

Choice B rationale:

Applying lubricant to the cannula tubing might help reduce friction but does not address the pressure that is causing the red mark.

Choice C rationale:

Placing padding around the cannula tubing helps to alleviate the pressure on the skin, which can prevent further irritation and allow the red mark to heal.

Choice D rationale:

Decreasing the flow rate to 1 L/minute could compromise the client’s oxygenation status, as the current flow rate is necessary to maintain an oxygen saturation level of 94%.

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Naxlex Comprehensive Predictor Exams

The nurse is planning assignments for the staff on a medical-surgical unit. Which task should the nurse assign to the practical nurse (PN)?

Correct Answer is C

Explanation

After obtaining an oxygen saturation level of 94% for a client with pneumonia who is receiving oxygen via nasal cannula at 3 L/minute, the nurse observes a red mark on the client's right cheek. Which intervention should the nurse implement?

Correct Answer is C

Explanation

The mother of a child born with Tetralogy of Fallot asks the nurse, "Why did this happen to my baby? What did I do wrong?" Which response by the nurse is most helpful?

The nurse learns that members of the nursing staff are uncomfortable with responding to client family members who are angry. While designing a teaching session to help the staff respond more effectively in these situations, which instructional strategy is best for the nurse to use?

Exhibits What other recommendations could the nurse give to help the patient have better sleep? Select all that apply.

The nurse identifies several nursing problems for a client who is incontinent and immobile after a stroke and is now experiencing diarrhea. The client resides at home, and the spouse is the primary caregiver. While planning care, the nurse should determine which problem has the highest priority?

During the admission assessment to the hospital, an adult client reports being allergic to latex, penicillin, and bananas. Which intervention should the nurse implement first?

When assessing a client with a serum potassium level of 2.5 mEq/L (2.5 mmol/L), which intervention is most important for the nurse to implement? Reference Range: Potassium (K+) 3.5 to 5 mEq/L (3.5 to 5 mmol/L)

An unlicensed assistive personnel (UAP) assigned to feed a client with meningococcal infection, for whom droplet precautions have been implemented, requests a change in assignment, reporting they have not yet been fitted for an N95 respirator mask. Which action should the nurse take?