A nurse is collecting data from a client who is at the end of life. Which of the following findings should the nurse expect?
Moist mucous membranes
Tachycardia
Irregular respirations
Hypertension
The Correct Answer is C
Explanation:
A. Moist mucous membranes - This is unlikely in an end-of-life scenario. As death approaches, mucous membranes often become dry due to decreased fluid intake and decreased body function.
B. Tachycardia - Tachycardia, or a rapid heart rate, can be a common finding as death nears. It can result from various factors such as dehydration, fever, pain, or the body's response to stress.
C. Irregular respirations - Irregular respirations, including periods of apnea or agonal breathing (gasping, irregular, or shallow breaths), are typical findings in the end-of-life stage. These irregularities are part of the body's natural process as it shuts down.
D. Hypertension - Hypertension is less common in the end-of-life phase. Typically, blood pressure decreases as the body's systems begin to fail.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Explanation:
A. Have a pen and paper.
Having a pen and paper can be helpful during the conversation as it allows the nurse to jot down important points, keywords, or reminders. However, it's not directly related to active listening itself but can aid in retaining and recalling information.
B. Use intermittent eye contact.
Intermittent eye contact is a crucial aspect of active listening. It shows that the nurse is engaged and attentive to the client's communication. However, it's essential to maintain a balance and avoid prolonged staring, which can be perceived as intimidating or intrusive.
C. Sit side-by-side with the client.
Sitting side-by-side with the client can create a sense of partnership and equality in the conversation. It can also help in establishing a comfortable and open environment for communication, which is beneficial for active listening.
D. Lean back in the chair.
Leaning back in the chair can convey a relaxed and open posture, which can contribute to a positive communication atmosphere. However, it's crucial to maintain an attentive posture and avoid appearing disinterested or unengaged.
Correct Answer is B
Explanation
Explanation:
A. Material safety data sheets:
Material safety data sheets (MSDS) are documents that provide information about the properties of chemicals and substances, including hazards, handling, storage, and emergency procedures. While MSDS are crucial for ensuring safe handling of materials, they primarily focus on chemical safety and may not provide detailed guidance on specimen collection protocols. Therefore, while MSDS are essential references for safety, they are not the primary source for revising specimen collection protocols.
B. Evidence-based practice:
Evidence-based practice (EBP) involves integrating the best available evidence from research studies, clinical expertise, and patient values and preferences to make informed decisions about patient care. For revising protocols, nurses should rely heavily on evidence-based guidelines and research literature related to specimen collection techniques, safety measures, accuracy, and quality assurance. EBP ensures that protocols are based on the latest scientific evidence, leading to improved patient outcomes and quality of care.
C. Client medical records:
Client medical records contain detailed information about individual patients, including their medical history, diagnoses, treatments, and laboratory results. While medical records are valuable for understanding specific patient needs and conditions, they are not typically used as primary sources for developing or revising unit-wide protocols. However, reviewing medical records may provide insights into specific challenges or issues related to specimen collection for certain patients.
D. Facility policy and procedures:
Facility policy and procedures manuals outline the organization's guidelines, protocols, and standards of practice for various aspects of patient care, including specimen collection. Nurses should refer to facility policies and procedures to understand existing protocols, safety measures, documentation requirements, and quality control processes related to specimen collection. While facility policies are important references, they may need to be updated based on current evidence and best practices, which is where evidence-based practice comes into play.
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