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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Setting the maximum water heater temperature to 54.4° C (130° F) is appropriate. This temperature is too high and could pose a burn risk, especially for someone with impaired vision who might not easily detect very hot water.
Choice B Reason:
Painting the edges of steps for contrast is appropriate. This measure helps increase visibility by creating a visual contrast between the edges of steps and the surrounding area, aiding the individual in identifying the steps more easily, even with reduced vision.
Choice C Reason:
Securing extension cords across walkways is inappropriate. Placing extension cords across walkways can create tripping hazards, particularly for someone with vision loss who may have difficulty seeing these obstacles.
Choice D Reason:
Using 40-watt bulbs to light hallways is inappropriate. While adequate lighting is crucial for individuals with vision impairment, using only 40-watt bulbs might not provide sufficient illumination. It's recommended to use higher-wattage bulbs or brighter lighting sources to ensure better visibility in the home.
Correct Answer is A
Explanation
Choice A Reason:
"I should advance my crutches up the step ahead of my unaffected leg" This statement demonstrates an understanding of the correct technique for ascending stairs with crutches. The client should advance the crutches onto the step first, followed by the unaffected leg.
Choice B Reason:
"I should keep my elbows straight when I am walking with my crutches": It is recommended to maintain a slight bend in the elbows to absorb shock and provide stability during crutch walking.
Choice C Reason:
"I will support my weight on the hand grips of the crutches": This is not an accurate statement. Weight should be supported through the hands and arms, not just the hand grips.
Choice D Reason:
"When I'm walking around my house with my crutches, it's okay to take my shoes off": Walking with crutches while barefoot can increase the risk of slipping and falling. It is generally recommended to wear supportive footwear.
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