A nurse caring for a client who is at home on hospice care.
At the end of the visit, the nurse reevaluates the client. Indicate if the assessment findings are improved, show no change, or show that the client has declined.
Client calm not agitated. Grimaces with movement.
Oral mucous membranes dry.
Axillary temp 102 F (38.9 C), client shivering.
Productive cough.
Coarse rhonchi bilaterally. Crackles in bases.
Respirations irregular with periods of apnea
Client resting in recliner. RR 12, regular
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"A"},"G":{"answers":"A"}}
Client calm not agitated. Grimaces with movement.
No change: While the client is calm and not agitated, grimacing with movement indicates continued discomfort or pain, which remains unchanged.
Oral mucous membranes dry.
No change: Dry oral mucous membranes persist, suggesting ongoing dehydration or inadequate oral hydration.
Axillary temp 102 F (38.9 C), client shivering.
Declined: The axillary temperature has increased from 100.8 F (38.22 C) to 102 F (38.9 C), indicating a worsening of the client's fever. Shivering suggests the body's attempt to generate heat in response to the fever.
Productive cough.
No change: The client continues to have a productive cough, indicating ongoing respiratory congestion or infection.
Coarse rhonchi bilaterally. Crackles in bases.
Declined: The presence of coarse rhonchi bilaterally and crackles in the bases suggests worsening respiratory status, possibly indicating progression of underlying lung disease or development of complications such as pneumonia.
Respirations irregular with periods of apnea.
Improved: The client's respirations, previously irregular with periods of apnea, are now regular, indicating an improvement in respiratory function.
Client resting in recliner. RR 12, regular.
Improved: The client's respiratory rate has decreased from 18 to 12 breaths per minute, and respirations are now regular, suggesting improved respiratory status and possibly reduced distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "I will be placing electrodes on your breasts": This statement is incorrect and may cause unnecessary concern or discomfort for the client. Electrodes for a 12-lead electrocardiogram are typically placed on the chest, not the breasts.
B. "I will lower the head of your bed so you can lie flat": This statement may be relevant for certain procedures but is not specific to applying electrode gel pads for a 12-lead electrocardiogram.
C. "Relax and try not to move or speak once I have attached the gel pads": This instruction is essential for obtaining a clear and accurate electrocardiogram recording. Movement or talking during the procedure can interfere with the quality of the tracing.
D. "Try to hold your breath until this procedure is complete": This instruction is unnecessary and could cause discomfort or anxiety for the client. There is no need for the client to hold their breath during a standard electrocardiogram procedure.
Correct Answer is C
Explanation
A. Docusate Sodium (Colace) is a stool softener and is not contraindicated in chronic renal disease.
B. Acetaminophen (Tylenol) is generally safe for use in chronic renal disease, but dosing adjustments may be necessary based on renal function.
C. Meperidine (Demerol) is contraindicated in clients with chronic renal disease because its metabolites can accumulate in renal impairment, leading to neurotoxicity and seizures. It is often replaced with alternative opioid analgesics like morphine or fentanyl in these patients.
D. Atorvastatin (Lipitor) is a statin medication used to lower cholesterol levels and is generally safe in chronic renal disease, although dosing adjustments may be needed depending on the severity of renal impairment.
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