A nurse is providing end-of-life care for a client. Which of the following actions should the nurse take?

Encourage the client to make choices regarding hygiene.

Oﬀer the client sips of a citrus ﬂavored soda.

Position the client supine in bed.

Suction the client's airway every hour.

Answer and Explanation

The Correct Answer is A

When providing end-of-life care for a client, the nurse should encourage the client to make choices regarding their hygiene. This allows the client to have some control over their care and can help them feel more comfortable.

Option b is incorrect because oﬀering the client sips of a citrus ﬂavored soda may not be appropriate for all clients and should be based on individual preferences and needs.

Option c is incorrect because positioning the client supine in bed may not be comfortable for all clients and should be based on individual preferences and needs.

Option d is incorrect because suctioning the client's airway every hour may not be necessary and should be based on individual needs.

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Correct Answer is B

Explanation

Crackles in the lungs indicate that the client is experiencing ﬂuid overload. When there is an excess of ﬂuid in the body, it can accumulate in the lungs and cause crackles. The other

a. Fever is not a sign of ﬂuid overload.

c. Bradycardia (a slow heart rate) is not a sign of ﬂuid overload.

d. Flattened neck veins are not a sign of ﬂuid overload; distended neck veins may be a sign of ﬂuid overload.

A. Assess skin temperature and color before applying the restraints. B. Ensure that the client's bed is in the lowest position. C. Secure restraints to allow three fingers to slide under the restraints. D. Pad bony prominences before applying the restraints. E. Attach the client's restraints to the bed rail.

Correct Answer is ["A","B","C","D"]

Explanation

When planning care for a client who has a prescription for extremity restraints on both wrists, the nurse should assess the client's skin temperature and color before applying the restraints to ensure that there is no circulation impairment. The nurse should also ensure that the client's bed is in the lowest position to prevent falls. The restraints should be secured to allow three fingers to slide under them to prevent injury and ensure proper circulation. Bony prominences should be padded before applying the restraints to prevent pressure injuries.

Option e is incorrect because attaching the client's restraints to the bed rail can cause injury if the bed rail is moved or adjusted.

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A nurse is providing end-of-life care for a client. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is receiving continuous IV ﬂuids through a peripheral IV. Which of the following findings indicates to the nurse that the client is experiencing ﬂuid overload?

Correct Answer is B

Explanation

A nurse is planning care for a client who has a prescription for extremity restraints on both wrists. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

Correct Answer is ["A","B","C","D"]

Explanation

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