Patient Data

Exhibits

Drag from the Word Choices to complete the sentence.

The nurse determines the client is near death as evidenced by

Decreased muscle tone, relaxed jaw muscles, sagging mouth

Congestion/increased pulmonary secretions; noisy respirations (death rattle)

Altered breathing (apnea, labored or irregular breathing, Cheyne- Stokes pattern)

Urine output is clear yellow

Eating soft foods

Answer and Explanation

Correct Answer : A,B,C

As patient goes into cardiorespiratory failure, there is altered breathing with characteristic gasping and death rattle before complete cessation of breathing. This is followed by cessation of the peripheral nervous system with loss of tone.

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Correct Answer is B

Explanation

A. Assault and battery involve intentional harmful or offensive contact with another person without their consent. Criminal assault is the threat of harm, while battery is the actual physical contact.
In this scenario, the nurse's actions were aimed at providing assistance to the victim, not causing harm. Therefore, criminal assault and battery would not apply.
B. Good Samaritan immunity protects individuals who provide assistance in emergency situations from liability for any injuries or damages that may occur as a result of their actions, as long as they act in good faith and without expectation of compensation. In this scenario, the nurse stopped to provide assistance voluntarily and acted in the victim's best interest. Good Samaritan immunity would likely apply in this situation, protecting the nurse from liability for any unintended consequences of their actions.
C. In this scenario, if the nurse failed to provide necessary care or took actions that deviated from the standard of care expected in similar circumstances, it could be considered negligent. However, the specific concern in this scenario is more aligned with abandonment of the victim rather than negligent acts of omission.

D. Abandonment occurs when a healthcare provider discontinues care without ensuring that the patient's needs are met or transferring care to another qualified individual. In this scenario, the nurse reported the victim's condition to EMS before leaving the scene. The nurse did not abandon the victim as they ensured that the victim received ongoing care from EMS.

A. While touching the client's forearm, asks, "Would you like to talk about it?" B. "I am sorry to disturb you at a difficult time. This can wait until later." C. Gives the client a hug and says, "It is okay to cry when you are sad." D. "This is a bad time. I can see you are upset. I can come back later.

Correct Answer is A

Explanation

A. This response is compassionate and invites the client to share their feelings. The gentle touch on the forearm can convey empathy and support, but it’s important to ensure that physical contact is appropriate for the client. This option encourages open communication while respecting the client’s feelings.

B.While this response acknowledges the client's distress, it also dismisses their feelings by suggesting that the assessment can be postponed. This can make the client feel invalidated or that their emotions are not important enough to address immediately.
C. This offers physical comfort and reassurance, but again, the nurse must be mindful of the client's boundaries and preferences regarding physical contact.
D. Recognizes the client's distress and offers to return later, which might be appropriate if the client prefers to be alone. However, this option fails to offer an opportunity for support to the client.

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Patient Data Exhibits Drag from the Word Choices to complete the sentence. The nurse determines the client is near death as evidenced by

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The nurse enters a client's room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?

Correct Answer is A

Explanation

Patient Data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

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The nurse observes the unlicensed assistive personnel (UAP) securing a client's wrist restraints to the bedside rails. Which action is most important for the nurse to implement?

The nurse is teaching a client about a newly prescribed medication. To confirm that the client is learning the critical information, which strategy is most important for the nurse to include during the instruction?

The nurse is administering an intradermal (ID) injection to a client. Which action should the nurse take?

The nurse is reviewing the admission assessment of a client with chronic pain. What intervention(s) should the nurse include in the client's plan of care? Select all that apply.

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A client who had emergency gallbladder surgery yesterday is getting ready for discharge. The client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client's understanding of self-care at home?

Patient Data

Exhibits

Drag from the Word Choices to complete the sentence.

The nurse determines the client is near death as evidenced by