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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Instruct the client to take an antiemetic before every meal to prevent excessive vomiting:While antiemetics can be helpful, this action may not address the underlying issue of food smells causing nausea. It is important to address the client’s sensory triggers.

B. Encourage family members to cook meals outdoors and bring the cooked food inside:
This can help reduce the trigger for nausea caused by the smell of cooking food. Cooking outdoors minimizes exposure to food smells, which could alleviate the client’s discomfort.

C. Assess the client's mucous membranes and report the findings to the healthcare provider: Assessing the mucous membranes is important in general care, especially for clients with cancer, but it is not directly related to the reported issue of nausea triggered by food smells.

D. Advise the client to replace cooked foods with a variety of different nutritional supplements: While nutritional supplements can be useful if the client is unable to tolerate solid foods, this advice doesn't address the root cause of the nausea related to food smells.

A. Prior to exercising. B. Before going to bed. C. Immediately after meals. D. During acute illness.

Correct Answer is D

Explanation

A. Prior to exercising: Testing before exercise is important, especially for clients on insulin, but may not be necessary for all clients depending on their diabetes management and regimen.

B. Before going to bed: This is often recommended for insulin-dependent diabetics to avoid nocturnal hypoglycemia, but it's not universally required for all clients.

C. Immediately after meals: Postprandial glucose testing is useful, especially for gestational diabetes or insulin adjustments, but it is not routinely required for all diabetics.

D. During acute illness: All clients with diabetes should monitor blood glucose more frequently during illness, as stress hormones can cause hyperglycemia or unexpected hypoglycemia.

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Naxlex Comprehensive Predictor Exams

The home care nurse visits a client who has cancer. The client reports having a good appetite but experiencing nausea when smelling food cooking. Which action should the nurse implement?

Correct Answer is B

Explanation

The nurse is planning a class about blood glucose monitoring for a group of clients with diabetes mellitus. Which timing of glucose testing would apply for any client regardless of the client's age or type of diabetes?

Correct Answer is D

Explanation

The nurse notices that a male client is particularly delusional one afternoon. He begins to pace the floor and appears to be losing control of himself. Which intervention is best for the nurse to implement?

A 3-year-old child is admitted with a Stage II Wilm's tumor. Which preoperative intervention(s) should the nurse implement? Choose all that apply.

Exhibits Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided. The diabetic nurse educator instructs the client to perform fingerstick blood glucose (FSBG) monitoring dropdownanddropdown.

An adult client receives a prescription for diphenhydramine 15 mL PO every 12 hours PRN for pruritus. The bottle is labeled, "Diphenhydramine 12.5 mg/5 mL." What is the total daily dose in mg that the client receives? (Enter numerical value only.)

A client receives a prescription for itraconazole. Which statement made by the client requires additional instruction by the nurse?