A nurse is caring for a client who has ovarian cancer and is in the end stages of the dying process.

Provider Prescriptions

Admission: Do-not-resuscitate (DNR) prescription 0940:

Oxycodone acetaminophen 5 mg/325 mg one tablet every 6 hr PRN for pain 1550:

Proceed with withdrawal of mechanically administered nutrition and hydration (MANH)

A nurse is planning care for a client who has requested withdrawal of medically administered nutrition and hydration (MANH). Which of the following should the nurse include in the plan of care? Select all that apply.
(Select All that Apply.)

Support client-requested rituals.

Encourage family to be present for MANH.

Following withdrawal of MANH, offer mouth sponges with preferred flavors as needed.

Request spiritual advisor visit, if applicable

Following withdrawal of MANH, suction oral cavity for pooling of secretions as needed

Educate client on the steps of the dying process

Answer and Explanation

Correct Answer : A,B,C,D,E

Supporting the client's rituals can provide comfort and dignity during this challenging time. It honors their preferences and cultural or religious beliefs, contributing to their overall well-being.

Having loved ones present can offer emotional support to both the client and their family members during the withdrawal of MANH. It allows for meaningful connections and facilitates closure.

Providing mouth sponges with preferred flavors can help alleviate dryness and discomfort in the oral cavity that may occur after the withdrawal of MANH. It promotes comfort and enhances the client's quality of life.

Spiritual support can be valuable for clients and their families during the end-of-life process. If the client desires spiritual guidance or support, arranging for a visit from a spiritual advisor can address their spiritual needs and provide comfort.

Suctioning the oral cavity for pooling secretions can help maintain the client's comfort and prevent aspiration, particularly if the client is unable to swallow effectively. It supports respiratory hygiene and comfort.

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Correct Answer is ["B","C"]

Explanation

This information is relevant to the client's condition and should be documented in the medical record. It provides important information about the client's physical status following the fall and may influence subsequent care decisions.

B. This information is typically documented in the incident report itself rather than the client's medical record. While it is important for the healthcare facility's records, it is not typically included in the client's medical record unless there are specific policies or procedures mandating such documentation.

C. This information is more relevant to administrative records and risk management procedures rather than the client's medical record.

D. This information is relevant to the client's care and should be documented in the medical record. It indicates that appropriate actions were taken following the incident.

A. Blood pressure B. Cyanosis C. Nausea D. Petechiae

Correct Answer is C

Explanation

Nausea refers to the sensation of feeling sick to the stomach, and it is a symptom that is reported by the client. Since it is based on the client's perception and cannot be directly observed by the nurse, it is considered subjective data.

A. Blood pressure is a measurable vital sign that can be obtained using a blood pressure cuff and stethoscope.

B. Cyanosis is a bluish discoloration of the skin or mucous membranes due to insufficient oxygenation of the blood.

D. Petechiae are small, pinpoint-sized red or purple spots on the skin that result from bleeding under the skin.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","C"]

Explanation

A nurse is completing a client's history and physical examination. Which of the following information should the nurse consider subjective data?

Correct Answer is C

Explanation

A nurse is using the Cultural Formulation Interview (CFI) tool while collecting a health history from a client who is from a culture different than the nurse. Which of the following statements should the nurse make?

A nurse is using a medical interpreter to communicate with a client. Which of the following actions should the nurse take?

A 35-year-old woman has been admitted to the hospital for a hysterectomy secondary to uterine cancer caused by smoking, and the nurse is collecting subjective data prior to surgery. Which statements by the nurse could be construed as non-judgmental? (Select All that Apply.)

A nurse is assessing a 6-year-old child who has experienced violence at school. Which of the following strategies should the nurse use during their assessment of this client?

The nurse is completing an assessment of a client who was sexually assaulted. What assessment should the nurse conduct last?

A nurse is asking a client who has schizophrenia about their cultural and spiritual beliefs. Which of the following is the purpose for collecting this information?

A student nurse is preparing a client room for the treatment of an ovarian cyst. What would be least important for the student nurse to do immediately before performing the client's physical exam with the primary nurse? (Select All that Apply.)

A nurse is caring for a client who has limited hand movement. Which of the following actions should the nurse take to assist the client with feeding?