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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Change in marital status: This is a psychological and social stressor rather than a physiological one.
B. Burn injury: A burn injury is a physiological stressor because it directly affects the body's physical systems and functions, causing a stress response.
C. Academic pressure: This represents a psychological and emotional stressor, impacting mental health and well-being, rather than physical systems.
D. Financial difficulties: Financial difficulties are psychological and social stressors, affecting emotional and mental health rather than physiological processes.
Correct Answer is C
Explanation
A. Place the chair at a 90° angle to the bed: Incorrect. The chair should be placed at an angle to facilitate a smoother transfer, usually around 45° to the bed, allowing easier movement from the bed to the chair.
B. Place the chair on the client's left side: Incorrect. The chair should be positioned on the strong side of the client if possible, or the side the client will be transferring towards, not necessarily the left side.
C. Lock the wheels on the client's bed: Correct. Locking the wheels on the bed ensures that the bed remains stationary during the transfer, providing safety and stability for the client.
D. Raise the height of the client's bed: Incorrect. The bed should be adjusted to a height that allows the nurse to safely transfer the client without excessive bending or stretching. However, raising it too high might make it difficult for the nurse to maneuver the client safely.
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