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A nurse is caring for a client who is in the late stage of the dying process.

Exhibits

Which of the following interventions should the nurse perform for this client? Select all that apply.

Place client in supine position with foot of bed elevated.

Place ice chips in mouth as needed.

Apply lubricating [LW1] ophthalmic drops PRN.

Administer furosemide 40 mg orally.

Administer albuterol nebulizer treatments 10 mg every 1 to 4 hr PRN.

Swab mouth with moisturizer as needed.

Answer and Explanation

Correct Answer : B,C,F

A. Supine with foot of bed elevated
Can worsen respiratory effort in dying clients.

B. Place ice chips in mouth
Helps soothe dry mouth and maintain comfort.

C. Lubricating eye drops PRN
Maintains moisture and prevents eye irritation when blinking diminishes.

D. Administer furosemide
Not indicated in comfort care/DNR-focus is not on aggressive fluid removal.

E. Albuterol every 1–4 hr
Not typically part of end-of-life comfort care unless specifically needed for comfort.

F. Swab mouth with moisturizer
Prevents dryness, cracking-important for comfort in the dying process.

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

Explanation

A. Insert a nasogastric (NG) tube.
Not part of the first-hour sepsis bundle; used for gastric decompression or nutrition later if needed.

B. Obtain blood cultures.
Cultures must be drawn before antibiotics to identify the causative organism.

C. Rapidly administer 30 mL/kg of normal saline.
Initial fluid resuscitation is essential to correct hypotension and improve perfusion.

D. Measure lactate level.
Elevated lactate indicates tissue hypoperfusion and helps guide treatment effectiveness.

E. Administer broad-spectrum antibiotics.
Timely antibiotics reduce mortality; must be given within 1 hour.

F. Obtain a urine specimen.
May help identify infection source, but not a priority in the first hour.

G. Obtain a wound culture.
Can be done later; blood cultures are the priority in sepsis.

H. Type and cross-match for 2 units of packed RBCs.
Only needed if there's evidence of hemorrhagic shock or anemia, which is not the case here.

A. Slow B. Not palpable C. Bounding D. Irregular

Correct Answer is D

Explanation

A. Slow
AFib may be slow, normal, or fast depending on rate control, so this is not always expected.

B. Not palpable
Pulses are usually present but irregular.

C. Bounding
Not typical of AFib.

D. Irregular
A hallmark feature of AFib is an irregularly irregular pulse.

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A nurse is caring for a client who is in the late stage of the dying process. Exhibits Which of the following interventions should the nurse perform for this client? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

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Correct Answer is D

Explanation

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A nurse is caring for a client who is in the late stage of the dying process.

Exhibits

Which of the following interventions should the nurse perform for this client? Select all that apply.