A nurse is caring for a client who is at the end of life.
Vital Signs:
Temperature 38.5° C (101.3° F),
Blood pressure 76/46 mm Hg,
Heart rate 112/min,
Respiratory rate 34/min, irregular,
Pulse oximetry 84% on 40% humidified face mask.
Which of the following 3 actions should the nurse plan to take?

Tell the client there is nobody else in the room.

Turn the client on their side.

Place a fan to blow lightly toward the client.

Administer an opioid narcotic to the client.

Provide deep nasotracheal suctioning for the client.

Answer and Explanation

Correct Answer : B,C,D

A. Tell the client there is nobody else in the room: This action is not appropriate as it does not address the immediate clinical needs of the client. Providing comfort and managing symptoms is a priority at the end of life.
B. Turn the client on their side: This action helps in relieving pressure, preventing aspiration, and improving respiratory function, which is particularly beneficial when a client is experiencing irregular and shallow breathing.
C. Place a fan to blow lightly toward the client: A fan can help alleviate discomfort from labored breathing and provide a cooling effect, which can be soothing for the client and improve their comfort.
D. Administer an opioid narcotic to the client: Opioids can help manage pain and dyspnea in end-of-life care, improving the client's comfort and quality of life by relieving symptoms of distress.
E. Provide deep nasotracheal suctioning for the client: This action is typically not recommended at the end of life as it can cause discomfort and distress without significant benefit. Gentle suctioning, if necessary, should be performed cautiously and with attention to the client's comfort.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["A","D","E","F"]

Explanation

A. The client will teach back information about safe crutch walking on day 1: This goal includes a specific time frame ("on day 1") which makes it a timed component. It establishes when the client is expected to demonstrate understanding, aligning with the SMART criteria for setting time-specific goals.

B. The client will demonstrate safe crutch walking: While this goal describes a desired outcome, it does not include a time frame, so it lacks the timing component needed for SMART criteria.

C. The client will not lean on the crutches to support their body weight: This goal focuses on the behavior change but does not specify when this should be achieved, missing the timed element of SMART goals.

D. The client will ambulate 5 feet in one day: This goal has a specific time frame ("in one day"), indicating when the client should achieve the goal, which is a critical aspect of SMART outcomes.

E. The client will walk 10 feet by day 2: This goal includes a specific time frame ("by day 2"), providing a clear deadline for achieving the goal, which is essential for SMART objectives.

F. The client will walk 20 feet by day 3: This goal includes a specific time frame ("by day 3"), which provides a deadline for reaching the goal, meeting the criteria for SMART goals.

G. The client will explain 4 principles of crutch safety: This goal describes an outcome but does not include a time frame, so it lacks the timed aspect necessary for SMART goals.

H. The client will explain how to keep crutches in safe condition: This goal focuses on an outcome without specifying a deadline, thus missing the timed component required for SMART goal setting.

A. Inhibits release of endorphins B. Improves sleep C. Decreases energy D. Decreases stress E. Increases mood

Correct Answer is B

Explanation

A. Inhibits release of endorphins: Exercise actually stimulates the release of endorphins, which are chemicals in the brain that help reduce pain and improve mood. Thus, this statement is incorrect.
B. Improves sleep: Exercise is known to enhance sleep quality by promoting better sleep patterns and reducing insomnia. This is a well-documented benefit of regular physical activity.
C. Decreases energy: Exercise typically increases overall energy levels rather than decreasing them. Regular physical activity helps in maintaining stamina and reducing fatigue.
D. Decreases stress: While exercise does help in managing stress, the primary benefit related to the is the improvement in sleep. Stress reduction is also a significant benefit but not the focus here.
E. Increases mood: Exercise can indeed elevate mood through the release of endorphins and other neurochemicals. However, improving sleep is a more direct and specific benefit related to the about exercise's benefits.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","D","E","F"]

Explanation

A nurse is teaching a client about the benefits of exercise. Which of the following information should the nurse include?

Correct Answer is B

Explanation

A nurse obtained a telephone order from a primary care provider for a patient in pain. Which chart entry should the nurse document?

A nurse is teaching a class about sources of stress. The nurse should include that which of the following is an example of a psychological stressor?

A nurse is teaching a client about using a cane for ambulation. Which of the following statements should the nurse make?

A nurse is teaching a class about physical manifestations associated with the fight-or-flight response to stress. Which of the following manifestations should the nurse include?

A hospice nurse tells another nurse that they are feeling overwhelmed after caring for multiple clients who are dying and reports having difficulty feeling sympathy for their clients. The nurse has manifestations of which of the following conditions?

The nurse working in the ER is admitting a toddler to the orthopedic unit. The parents and grandparents are at bedside. What should the nurse use as the best source of data for this client?

A nurse is teaching a newly licensed nurse about orthostatic hypotension. Which of the following information should the nurse include?