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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Wear closed-toe shoes that are comfortable and fit well: Wearing well-fitting shoes helps prevent foot injuries and complications, which are common in people with diabetes due to neuropathy and poor circulation. Foot care is crucial for diabetes management.

B. Obtain an A1C blood test every year to monitor glucose control: The A1C test should be done at least twice a year if the client’s blood sugar is under control, or more often if adjustments are needed.

C. Check blood sugar levels every four to six hours every day: Most individuals with type 2 diabetes need to check blood sugar based on specific times like before meals or once daily, not every few hours.

D. Restrict alcoholic beverages to no more than 1 to 2 per week: Moderate alcohol intake may be allowed in some cases, but more frequent consumption can affect blood sugar. The goal is to limit intake, not restrict to a specific number per week.

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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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing teaching to a client newly diagnosed with type 2 diabetes mellitus about disease management. Which response by the client indicates understanding?

Correct Answer is A

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?

Exhibits The client asks the diabetic nurse educator to clarify what the Registered Dietician told her about the content and timing of her meals. Which 3 responses should the diabetic nurse educator provide?

The nurse is demonstrating correct transfer procedures to the unlicensed assistive personnel (UAP) working on a rehabilitation unit. The UAP asks the nurse how to safely move a physically disabled client from the wheelchair to a bed. Which action should the nurse recommend?

Exhibits The client has started to wake up more, opening her eyes without stimulation and looking around the room. Which should the nurse do as the client becomes more aware of her surroundings? Select all that apply.

The nurse plans to collect a 24 hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client?