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 B

Explanation

A. While documenting the color and clarity of the urine is important for assessing the client's urinary output and potential issues, it is not the immediate next step in the catheter insertion process. This step typically comes after the catheter is fully inserted and secured.
B. Once urine flow is observed, the next step is to inflate the balloon of the indwelling catheter to secure it in place within the bladder. This ensures the catheter remains correctly positioned and does not move out of the bladder, which is crucial for effective drainage and preventing accidental dislodgement.
C. Asking the client to breathe deeply and exhale does not impact the catheterization process and is not related to the next immediate step after observing urine flow. This action might be helpful in other contexts, such as reducing anxiety or discomfort, but it does not address the technical steps required for catheter insertion.
D. If urine flow is observed in the catheter, it indicates that the catheter is already in the bladder. Inserting the catheter an additional inch is unnecessary and could potentially cause trauma or discomfort. Proper catheter placement is confirmed by the observation of urine flow, and additional insertion is not required.

A. Obtain a clean, voided urine specimen for analysis. B. Evaluate the client's response to bladder training efforts. C. Place a protective undergarment on the client. D. Encourage increased fluid intake for 24 hours.

Correct Answer is A

Explanation

A. Urinary incontinence in an older adult can be a symptom of various underlying conditions, such as urinary tract infections, dehydration, or cognitive impairment. Obtaining a urine specimen for analysis can help to identify the underlying cause of the incontinence and guide appropriate treatment.
B. Bladder training is a technique used to improve bladder control and reduce incontinence. However, it's not appropriate to evaluate the client's response to bladder training efforts when they have suddenly become disoriented and developed incontinence. This suggests a potential underlying medical condition that needs to be addressed first.
C. While protective undergarments can be helpful in managing incontinence, they do not address the underlying cause of the problem. It's important to identify and treat the underlying condition to improve the client's quality of life and prevent complications.
D. While dehydration can sometimes contribute to incontinence, it's not appropriate to increase fluid intake in a client who has suddenly become disoriented. This could worsen their condition, especially if they have cognitive impairment or other underlying medical conditions.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While inserting an indwelling urinary catheter into a female client, the nurse observes urine flow in the tubing. Which action should be taken next?

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?

Correct Answer is A

Explanation

Which assessment is most important for the nurse to perform prior to the application of a heating pad?

The nurse is teaching another nurse about the administration of medication using the Z track technique. Which is the primary reason for using a Z track technique to administer a medication?

When preparing to change a client's sterile dressing, the nurse pours sterile solution over a package of gauze pads as seen in the picture. Which should the nurse do next?

The nurse is completing an assessment of an older adult client recovering from a total hip replacement. The client reports a decreased appetite and is concerned about having not had a bowel movement for several days. Which intervention should the nurse implement first?

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?

A client is ambulating with a two wheeled walker by rolling the walker forward and then moving each foot forward. The nurse notes that the client's elbows are slightly flexed when grasping the hand bar. After the client returns to the chair, which action should the nurse implement?

The nurse is assessing an older female client who was admitted to a long-term facility two days ago. The resident refuses to go to the dining room for meals and calls for help with all activities of daily living. Which nursing problem is best to include in this client's plan of care?