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:
Inflating the catheter's balloon is inappropriate. Inflating the balloon at this point is not recommended. The balloon should only be inflated once the catheter is in the bladder and urine starts to flow.
Choice B Reason:
Twisting the catheter gently is appropriate. Twisting the catheter gently may help navigate any obstruction or resistance within the urethra. However, it is crucial to be cautious and not force the catheter. If resistance persists or if the catheter cannot be advanced further, the nurse should reassess the situation and consider alternative actions, such as selecting a smaller catheter or seeking assistance from a more experienced healthcare provider.
Choice C Reason:
Applying lidocaine gel to the urethra is inappropriate. Applying lidocaine gel may be appropriate for lubrication and to minimize discomfort during catheter insertion, but it will not address the issue of resistance or lack of urine flow.
Choice D Reason:
Lowering the penis to a 45° angle is inappropriate. Adjusting the angle of the penis is not likely to resolve the issue of resistance. Twisting the catheter gently or reassessing the situation would be more appropriate.
Correct Answer is A
Explanation
Choice A Reason:
"I should advance my crutches up the step ahead of my unaffected leg." This statement demonstrates correct technique for ascending stairs with crutches. When going up stairs, 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." The client should maintain a slight bend in the elbows while walking with crutches to provide stability and support.
Choice C Reason:
"I will support my weight on the hand grips of the crutches." The client should not support their weight on the hand grips alone; weight should be distributed through the hands and arms to avoid putting excessive pressure on the axillae.
Choice D Reason:
"When I'm walking around my house with my crutches, it's okay to take my shoes off." It is generally not advisable to walk with crutches without shoes, as wearing shoes provides better support and stability. The client should wear supportive, non-skid footwear while using crutches.
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