An older woman who was recently diagnosed with end stage metastatic breast cancer is admitted because she is experiencing shortness of breath and confusion. The client refuses to eat and continuously asks to go home. Arterial blood gas results indicate hypoxia. Which intervention is most important for the nurse to implement?
Clarify end of life desires.
Offer sips of favorite beverages.
Initiate comfort measures.
Prepare for emergent oral intubation.
The Correct Answer is C
A. Clarify end of life desires: While understanding a client’s goals is vital, this may not address her immediate needs. The client is already showing signs of distress and hypoxia, so initiating comfort measures promptly is more urgent than discussing future preferences.
B. Offer sips of favorite beverages: Offering fluids may help with oral comfort but does not address the client’s respiratory distress or overall suffering. It is a low-priority intervention in the setting of acute hypoxia and confusion related to terminal illness.
C. Initiate comfort measures: Comfort measures are the priority for a terminally ill client with hypoxia and confusion who is refusing food and expressing a wish to go home. This aligns care with the client's likely stage in the dying process and ensures symptom relief over aggressive interventions.
D. Prepare for emergent oral intubation: Intubation is invasive and likely inconsistent with palliative goals in end-stage cancer. Without clear patient consent or indication that life-prolonging measures are desired, focusing on comfort is more appropriate and ethical.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Frequency that the child uses a rescue inhaler during the week: While it is important to know how often the child uses a rescue inhaler, it does not provide immediate, critical information to assess the severity of the current asthma attack.
B. Type of inhaler the child typically uses on a regular basis: While knowing the type of inhaler the child uses regularly can provide insight into their asthma management, it is not the most critical information at this moment, the current treatment is he most urgent.
C. Type of allergen exposure or trigger for the current episode: Understanding the trigger for the current asthma episode is helpful for long-term management but is not as urgent in the immediate assessment of the child’s condition during an acute exacerbation.
D. Last dose and type of rescue inhaler used by the child: This information helps assess whether the child has received appropriate treatment and whether additional or different interventions are needed immediately to address the asthma exacerbation, helps guide further treatment decisions.
Correct Answer is B
Explanation
A. Tie the knot with a double turn or square knot: While using a secure knot is important, the most critical factor is that the knot can be easily and quickly released in an emergency. A half bow knot may be inadequate for rapid release, but the primary focus should be ensuring quick accessibility.
B. Ensure that the knot can be quickly released: This is the most important action to ensure the safety of the client. In the event of an emergency, such as difficulty breathing or a need to quickly remove restraints, the knot must be easily undone without delay.
C. Move the ties so the restraints are secured to the side rails: Tying restraints to side rails is inappropriate because the side rails can move, which may result in injury. Restraints should be attached to a stationary part of the bed frame.
D. Ensure that the restraints are snug against the client's wrists: While restraints should be applied snugly to prevent injury, they should not be too tight. The primary concern here is ensuring that the restraints are safely and quickly releasable, not just snug.
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