A client with end stage metastatic cancer has a living will stating no extraordinary measures are to be taken as death approaches, and the healthcare provider writes a "Do Not Resuscitate" (DNR) prescription. When the client begins to take gasping breaths, the nurse determines the client's oxygen saturation is 85%. Which action should the nurse implement?

Manually ventilate using a bag valve mask apparatus.

Determine if client wishes have changed.

Report client's status to the healthcare provider.

Administer oxygen via a nasal cannula.

Answer and Explanation

The Correct Answer is D

A.   Using a bag valve mask (BVM) to manually ventilate the client would be considered an extraordinary measure, which conflicts with the client's living will stating no extraordinary measures should be taken.
B.   While it's essential to ensure that the client's current wishes are respected, the client is likely unable to communicate effectively due to their condition. If the client were able to express their wishes at this stage, it might be important to confirm, but given the client's living will and the established DNR order, the primary focus should be on adhering to these documents.
C.   Reporting the client's status to the healthcare provider is important to ensure that the provider is informed about the client’s current condition and can offer guidance or make necessary adjustments in the care plan. However, if the healthcare provider is already aware of the client's living will and DNR order, this step may be secondary to following the existing orders.
D.   Administering supplemental oxygen via a nasal cannula is a palliative measure that can provide comfort without being considered an extraordinary measure. It aligns with the goal of providing symptom relief and comfort care rather than resuscitation or life-extending interventions.

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Correct Answer is D

Explanation

A. While it is generally good practice to measure blood pressure in both arms for a comprehensive assessment, this is not the primary concern with hypocalcemia. Hypocalcemia primarily affects neuromuscular and cardiovascular systems, so while blood pressure monitoring is important, it does not directly address the critical symptoms associated with low calcium levels.
B. Assessing skin turgor is a useful practice for evaluating hydration status and skin elasticity but is not specifically related to the management or symptoms of hypocalcemia. In hypocalcemia, skin changes are not the most relevant concern compared to neuromuscular symptoms.
C. Hypocalcemia can increase the risk of bleeding and bruising due to impaired blood clotting mechanisms. Monitoring for bruising can be an important aspect of assessing the effects of low calcium levels on the client’s hemostatic function. Bruising can be a direct indicator of the impact of hypocalcemia on blood coagulation and is relevant to the clinical management of the condition.
D. Hypocalcemia can affect cardiac function, potentially leading to changes in heart rhythm and rate. Monitoring the rhythm of the pulse is crucial, as it can help identify arrhythmias or other cardiac disturbances associated with low calcium levels.

A. Blood pressure is 142/88 mm Hg. B. 2+ edema of fingers and hands. C. Capillary refill time is 2 seconds. D. Radial pulse volume is 3+.

Correct Answer is B

Explanation

A. Elevated blood pressure can be a concern for overall cardiovascular health but it does not directly affect the accuracy of pulse oximetry readings.
B. Edema, or swelling, of the fingers and hands can affect the accuracy of pulse oximeter readings. Edema can impede proper light transmission through the finger, leading to falsely low oxygen saturation readings.
C. A capillary refill time of 2 seconds is within normal limits, indicating adequate peripheral perfusion. It is unlikely to affect pulse oximeter readings significantly, so this is not a likely cause of a low oxygen saturation reading.
D. A radial pulse volume of 3+ indicates a strong, full pulse. This finding typically suggests good peripheral circulation and is not likely to impact the accuracy of pulse oximetry readings.

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Naxlex Comprehensive Predictor Exams

A client has a total serum calcium level of 7.0 mg/dL (1.75 mmol/L). Based on this information, which action is most important for the nurse to include while measuring the client's vital signs? Reference Range: Total Calcium (9 to 10.5 mg/dL (2.25 to 2.62 mmol/L)]

Correct Answer is D

Explanation

The nurse attaches a pulse oximeter to a client's finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

Correct Answer is B

Explanation

An older adult client residing in a long-term care facility has become disoriented and suddenly develops urinary incontinence. Which intervention should the nurse implement?

A client is admitted to the rehabilitation unit following a cerebrovascular accident (CVA), which resulted in paralysis of the right arm. When the nurse enters the room, the client is struggling to put on a shirt, and curses at the nurse. Which response is best for the nurse to provide?

An older client with colorectal carcinoma receives a colostomy following a bowel resection and the nurse is reviewing written instructions about colostomy care that the client will take home after discharge. Which action should the nurse include when reviewing the instructions with the client?

The unlicensed assistive personnel (UAP) tells the nurse that an older client has requested powder applied after a tub bath to relieve itchy dry skin. Which instruction should the nurse provide to the UAP?

The nurse identifies the hospitalized client in which situation as being at highest risk for the development of a healthcare associated infection (HAI)?

A client's spouse has just learned of the client's terminal illness. The spouse is sitting in the corner of the client's room crying, and says to the nurse, "I feel as if I'm already so alone." Which action should the nurse take first?

Prior to receiving a 120 mL hypertonic enema, an ambulatory female client tells the nurse that she does not believe that she can walk all the way to the bathroom without expelling the enema. Which intervention is best for the nurse to implement?

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?