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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Related Questions
Correct Answer is A
Explanation
Explanation:
A. Right communication:
This refers to providing clear and concise instructions to the assistive personnel regarding the delegated task. Effective communication ensures that the AP understands the task, its objectives, any limitations or special considerations, and the expectations regarding its completion. Clear communication helps prevent misunderstandings and promotes safe and efficient task execution.
B. Right room:
This choice does not directly relate to the five rights of delegation. The "right room" concept may refer to ensuring that the environment or room where care is provided is appropriate, safe, and conducive to the task being performed. While environmental factors are important in healthcare, they are not part of the specific rights of delegation.
C. Right time:
The "right time" aspect of delegation involves considering the timing of the task within the overall care plan. It includes assessing whether the task should be performed immediately, at a specific time, or within a particular timeframe. Delegating tasks at the right time ensures that they align with the client's needs and the overall care schedule.
D. Right documentation:
This refers to documenting the delegation process, including details such as the delegated task, the personnel involved, any specific instructions or limitations provided, and the outcomes or results of the task. Documentation is crucial for accountability, continuity of care, and legal purposes, ensuring that there is a record of who performed the task and how it was carried out.
Correct Answer is D
Explanation
Explanation:
A. Evaluating the collected data:
This step in EBP involves assessing and analyzing the data that has been gathered through research or other sources. It includes examining the quality, relevance, and reliability of the data to determine its applicability to the clinical question or problem being addressed. Evaluation of data is crucial in EBP to ensure that decisions and interventions are based on sound evidence.
B. Implementing recommendations:
Implementing recommendations is a later step in EBP that comes after evaluating the evidence. Once credible sources have been identified, and the data has been analyzed, recommendations or interventions based on the best available evidence are put into practice. This step involves applying evidence-based guidelines, protocols, or interventions to patient care to improve outcomes and quality of care.
C. Identifying a problem:
This is the initial step in the EBP process where a specific clinical problem or question is identified. It involves recognizing gaps in knowledge, areas of uncertainty, or issues that require improvement in clinical practice. Identifying a problem is essential as it sets the stage for formulating focused research questions and seeking relevant evidence to address the problem effectively.
D. Searching for credible sources:
Searching for credible sources is a critical step in EBP where healthcare professionals gather evidence from reputable and reliable sources. This includes conducting literature searches, accessing databases, and reviewing published studies, clinical guidelines, systematic reviews, and other scholarly sources. The goal is to find the best available evidence to answer clinical questions, guide decision-making, and inform evidence-based practice.
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