A nurse is educating a terminally ill patient about declining resuscitation in a living will.
The patient asks, “What would happen if I arrived at the emergency department and I had difficulty breathing?” Which of the following responses should the nurse make?

“We would give you oxygen through a tube in your nose.”.

“You would be unable to change your previous wishes about your care.”.

“We would insert a breathing tube while we evaluate your condition.”.

“We would consult the person appointed by your health care proxy to make decisions.”. .

Answer and Explanation

The Correct Answer is A

Choice A rationale

If a patient with a living will arrived at the emergency department with difficulty breathing, the healthcare team would provide immediate care to ease the patient’s distress, such as administering oxygen.

Choice B rationale

While a living will outlines a patient’s wishes for end-of-life care, it does not prevent the patient from receiving immediate, necessary care in an emergency situation.

Choice C rationale

Inserting a breathing tube may be necessary in some cases, but it would not be the first step in managing difficulty breathing.

Choice D rationale

While the healthcare team would consult the person appointed by the patient’s healthcare proxy to make decisions, immediate care would not be delayed.

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Correct Answer is C

Explanation

Choice A rationale

Assisting the client to a left side-lying position with the right knee flexed is a common position for administering an enema. However, this action alone would not address the client’s immediate need for relief from constipation.

Choice B rationale

Preparing the client for a chest x-ray would not be the most appropriate action based on the client’s symptoms. The client is experiencing abdominal pain and constipation, which are not typically associated with conditions that would require a chest x-ray.

Choice C rationale

Administering a cleansing enema is the correct action. The client has not had a bowel movement for the past 7 days and reports abdominal pain. These symptoms, along with the findings from the abdominal x-ray, suggest that the client is experiencing constipation. A

cleansing enema can help to relieve constipation by stimulating bowel movements and removing impacted fecal matter.

Choice D rationale

Auscultating the client’s bowel sounds is an important part of assessing the client’s gastrointestinal status. However, given the client’s symptoms and the results of the abdominal x-ray, administering a cleansing enema would be the most appropriate action.

A. Insert the suction catheter while the patient is swallowing. B. Apply intermittent suction when withdrawing the catheter. C. Place the catheter in a location that is clean and dry for later use. D. Hold the suction catheter with their clean, non-dominant hand.

Correct Answer is B

Explanation

Choice A rationale

Inserting the suction catheter while the patient is swallowing is not the recommended technique for nasotracheal suctioning. This could cause discomfort and potentially lead to aspiration.

Choice B rationale

Applying intermittent suction when withdrawing the catheter is the correct technique for nasotracheal suctioning. This helps to remove secretions effectively while minimizing trauma to the nasal and tracheal mucosa.

Choice C rationale

Placing the catheter in a location that is clean and dry for later use is not a recommended practice. After suctioning, the catheter should be properly cleaned or disposed of to prevent infection.

Choice D rationale

Holding the suction catheter with their clean, non-dominant hand is not a recommended practice. The nurse should use clean gloves and proper hand hygiene when performing nasotracheal suctioning to prevent infection.

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A nurse is educating a terminally ill patient about declining resuscitation in a living will.The patient asks, “What would happen if I arrived at the emergency department and I had difficulty breathing?” Which of the following responses should the nurse make?

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Naxlex Comprehensive Predictor Exams

A client in the emergency department reports abdominal pain and has not had a bowel movement for the past 7 days. Based on the client’s clinical findings, which action should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a patient who has a respiratory infection.What technique should the nurse use when performing nasotracheal suctioning for the patient?

Correct Answer is B

Explanation

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A nurse is educating a terminally ill patient about declining resuscitation in a living will.
The patient asks, “What would happen if I arrived at the emergency department and I had difficulty breathing?” Which of the following responses should the nurse make?