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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Explanation:
A. Nonmaleficence: This ethical principle emphasizes the duty of healthcare professionals to avoid causing harm to patients. It involves refraining from actions that could potentially harm the patient, whether physical, emotional, psychological, or social. Nonmaleficence is about acting in a way that promotes the well-being and safety of patients and avoiding actions that could result in harm or injury.
B. Fidelity: Fidelity pertains to the faithfulness, loyalty, and honoring of commitments and promises made to patients. It involves maintaining trust and being truthful in interactions with patients.
C. Beneficence: Beneficence involves the obligation to do good and promote the well-being of patients. It includes actions aimed at benefiting patients, such as providing effective treatments, interventions, and support to improve their health outcomes and quality of life.
D. Justice: Justice relates to fairness and equality in healthcare. It involves the fair distribution of resources, allocation of care, and treatment decisions without discrimination or bias, ensuring that all patients receive equitable care based on their needs and circumstances.
Correct Answer is D
Explanation
Explanation:
A. "There are 4 rights of delegation."
This statement is not entirely accurate. Delegation involves several principles, including the right task, right circumstances, right person, right direction/communication, and right supervision/evaluation. Therefore, simply stating "4 rights" does not fully encompass the principles of delegation.
B. “The nurse manager is responsible for delegating nursing tasks during each shift."
This statement is incorrect. While the nurse manager may have oversight and authority regarding delegation policies and procedures, it is typically the responsibility of the delegating nurse (the one assigning tasks) to delegate appropriate tasks to qualified individuals based on their competency and scope of practice.
C. "It is the duty of the delegatee to perform a task without asking questions when it is delegated."
This statement is not accurate and could lead to misunderstandings or errors. Effective delegation involves clear communication, which includes the opportunity for the delegatee to ask questions if they are unsure about any aspect of the delegated task. Encouraging questions helps ensure that the task is understood and performed safely and appropriately.
D. “I am responsible for ensuring that a delegated task is completed."
This statement demonstrates understanding of delegation principles. The delegating nurse (the one assigning tasks) is indeed responsible for ensuring that delegated tasks are appropriate, communicated effectively, and completed according to established standards. This includes providing necessary guidance, supervision, and follow-up to ensure task completion and quality of care.
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