A nurse is caring for a client who is terminally ill and has a do-not-resuscitate order on his medical record. The client asks, "What should I do if I have difficulty breathing?" Which of the following responses should the nurse make?

"Call me so that I can help you change your position."

"Try to close your eyes and get some sleep."

"It is common for breathing to become more difficult as time goes on."

"Therapy choices are limited for clients who do not want resuscitation."

Answer and Explanation

The Correct Answer is A

Choice A Reason:

"Call me so that I can help you change your position." This response offers practical assistance and comfort to the client. Repositioning can sometimes alleviate discomfort associated with breathing difficulties, and the nurse can offer guidance or physical help to adjust the client's position for improved comfort.

Choice B Reason:

"Try to close your eyes and get some sleep." This response doesn't directly address the client's immediate concern about difficulty breathing and may not offer practical help.

Choice C Reason:

"It is common for breathing to become more difficult as time goes on." While this statement acknowledges the situation, it might not provide the client with actionable guidance or support on how to manage the difficulty in breathing.

Choice D Reason:

"Therapy choices are limited for clients who do not want resuscitation." This response might be interpreted as dismissive or unrelated to the client's immediate needs, focusing more on the DNR order rather than addressing the current concern about breathing difficulties.

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Correct Answer is C

Explanation

Choice A Reason:

Adding diluent to the medication is not appropriate for ampules. Ampules typically contain a single-dose of medication in a liquid form.

Choice B Reason:

The ampule should be cleansed before opening to remove any potential contaminants. Once the ampule is opened, the inside of the ampule and the medication should be considered sterile, so there is no need to cleanse the tip after opening.

Choice C Reason:

A filter needle is used to prevent any glass particles from entering the syringe when drawing medication from an ampule, as ampules are made of glass that can sometimes break and leave shards.

Choice D Reason:

Injecting air into the ampule is not necessary. Ampules are designed to allow for the withdrawal of medication without the need to inject air.

A. Check a client's peripheral IV site for redness or swelling. B. Measure the intake and output of a client who has received furosemide. C. Reinforce teaching with a client about crutch-gait walking. D. Assess the pain level of a client who has received acetaminophen.

Correct Answer is B

Explanation

A. Check a client's peripheral IV site for redness or swelling.
This task involves assessing the client's IV site for signs of complications. While it requires observation and reporting, it may involve some interpretation and judgment. This task is better suited for a licensed nurse.

B. Measure the intake and output of a client who has received furosemide.
Measuring intake and output is a routine task that involves quantifying the fluids a client consumes and eliminates. This is a task that can be appropriately delegated to an assistive personnel (AP) under the supervision and direction of the nurse.

C. Reinforce teaching with a client about crutch-gait walking.
Teaching requires a level of education, explanation, and clarification that goes beyond routine tasks. This is typically a nursing responsibility and should not be delegated to an AP.

D. Assess the pain level of a client who has received acetaminophen.
Pain assessment involves subjective information, and determining the appropriate response may require clinical judgment. This task is better suited for a licensed nurse.

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A nurse is caring for a client who is terminally ill and has a do-not-resuscitate order on his medical record. The client asks, "What should I do if I have difficulty breathing?" Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?

Correct Answer is C

Explanation

A nurse is coordinating care of a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

Correct Answer is B

Explanation

A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about incident reporting. The nurse should identify that it is necessary to complete an incident report for which of the following situations?

A nurse is reinforcing teaching with a client who has an ostomy. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is reinforcing teaching with a group of newly licensed nurses regarding client confidentiality. In which of the following situations nurse disclose health information without the client's written consent?

A nurse is caring for a client who is scheduled for a CT scan that requires contrast dye. Which of the following actions is the priority for the nurse to take?

A nurse is reviewing a client's medication administration record at 1930. The nurse notes that the documentation for the 1700 regular insulin dose is missing. Which of the following is an appropriate action for the nurse to take?

A nurse observes an assistive personnel (AP) perform mouth care for a client who is unconscious. Which of the following actions by the AP requires intervention by the nurse?

A nurse is caring for a client who has an indwelling urinary catheter and a prescription for furosemide. Which of the following actions should the nurse take?

A nurse is replacing a dressing for a client who has an abdominal incision with a closed wound drain. Which of the following actions should the nurse take?