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 C
Explanation
A. Acute pain manifested by client's report: This diagnosis is too general and does not address the specific issue of unknown etiology or the need for further investigation.
B. Acute pain related to psychosomatic condition: This diagnosis assumes a psychosomatic cause without sufficient evidence. The cause of the pain is not yet clear, so this may not be accurate.
C. Acute pain related to unknown etiology: This diagnosis accurately reflects the situation of pain with an unclear cause and is appropriate for guiding further assessment and investigation.
D. Acute pain related to unknown factors: This diagnosis is vague and less specific than "unknown etiology," which provides a clearer framework for understanding the cause of the pain.
Correct Answer is A
Explanation
A. Financial difficulties: Correct. Financial difficulties are a psychological stressor as they impact mental and emotional well-being, contributing to stress.
B. Hypothermia: This is a physiological stressor, as it involves a physical condition affecting the body's health rather than psychological aspects.
C. Burn injury: This is also a physiological stressor resulting from physical harm rather than a psychological impact.
D. Wrist fracture: This is a physical stressor due to injury, not a psychological one, as it affects physical health rather than mental well-being.
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